The lead article in this month’s edition of Perspectives details their revised pain management standards. Initiating and implementation a plan soon is important with the standards due to take effect January 1, 2018.
There are seven leadership elements of performance relative to pain management including the following new requirements.
- Establish or identify a leader or leadership team that is responsible for pain management and safe opioid prescribing and PI activities.
- Provide nonpharmacologic pain treatment modalities
- Supply staff and LIP’s with resources and programs to improve pain assessment and management.
- Provide staff and LIP’s consultation or referral resources for patients with complex pain management needs.
- Identify opioid treatment programs to use for referrals.
- Facilitate practitioner and pharmacist access to the Prescription Drug Monitoring Program databases that are maintained in your state.
- Leadership works with clinical staff to identify and acquire the equipment needed to monitor patients who are at high risk for adverse outcomes from opioid treatment.
Furthermore, a new medical staff EP, MS.05.01.01, EP 18 requires the medical staff to take active involvement in pain assessment. That interaction includes pain management and safe opioid prescribing by establishing protocols and quality metrics and reviewing PI data. Corollary requirements at PI.01.01.01 and PI.02.01.01 to collect data on pain assessment and pain management, including the types of interventions and effectiveness are included.
For example, EP 18 at PI.02.01.01 requires the hospital to analyze the data on pain assessment, pain management and to identify the need to increase safety and quality for patients. Then EP 19 requires the hospital to monitor the use of opioids to determine if they are being used safely. Tracking adverse events such as respiratory depression, naloxone usage and the duration of opioid prescriptions are all included.
The existing Provision of Care standards at PC.01.02.07 are modified, deleting the existing EP 1 comprehensive pain assessment expectation. The new standard requires a defined criteria to screen, assess and reassess pain that are consistent with the patients age, condition and ability to understand. This requirement does have a D for documentation. EP 4 of this standard then establishes a need for a pain treatment plan and pain management goals. Documentation is a requirement here as well. EP 5, another D, requires patient involvement in the treatment planning process. This involvement includes developing realistic expectations and measurable goals, discussing the objectives and providing education. EP 6 then requires that patients identified as being at high risk for adverse outcomes. EP 7 discusses required reassessment activities. There are four bullet points, each requiring documentation. These are:
- Evaluation and documentation of response to pain interventions
- Progress toward pain management goals including functional ability
- Side effects
- Risk factors for adverse events
Lastly EP 9 requires the education of the patient and family on discharge plans related to pain management including four bulleted items. These are:
- Pain management plan of care
- Side effects of pain management treatment
- Activities of daily living including the home environment that might exacerbate or reduce effectiveness of the pain management plan of care
- Safe use, storage, and disposal of opioids when prescribed
New Pain Management Standards
As you can tell, adhering to these new pain management standards by January 1, 2018 will require some work. Starting ASAP is critical. The leadership team might be an existing multidisciplinary group like your pharmacy and therapeutics committee. Or, if you have pain management specialists or a department, forming a new group using them as a resource may be appropriate.
In addition, providing educational resources and programs on pain management might include grand rounds, webinars, podcasts or a new resource on your hospital intranet. Meeting consultation needs through pain management specialists or a telemedicine resource for small or rural hospitals are good options. Urban areas should be able to identify opioid treatment and referral opportunities for referral. But, this may be more challenging in small and rural areas, or wait lists in urban areas. The facilitation of access to state operated prescription drug monitoring programs sounds like a good idea. We see that occasionally on consults, but not often enough. Reviewing the work done by the VA may be a good starting point. Their work includes clinical practice guidelines for chronic pain and support of complementary and integrative healthcare (CIH) and the biopsychosocial model of pain care.
The new medical staff and performance improvement expectations will require some thoughtful analysis to determine what you want to measure. In addition, determining how you will display or present the data in a meaningful is important. In this case it might be your pain management leadership person or team presenting to the medical executive committee periodically.
EMR Refinements Likely
The provision of care standards will probably require some EMR refinements and these always take time to implement. Template a treatment plan goal for pain management, if you don’t already have one. Developing educational content and formatting on the educational log may take some time along with space to document monitoring of progress on the plan of care. EP 6, the one that requires monitoring patients who are at high risk for adverse outcomes is an interesting one.
Three years ago, CMS sent an SC memo 14-15 that in some respects was similar to the Joint Commission’s Sentinel Event Alert on safe opioid use. However, CMS called for assessment of patient types at greatest risk for adverse effects of opioids. For example, the elderly, those with long surgeries and anesthesia, the opiate naïve and the opiate addicted. As a result, CMS advised to identify and use capnography monitoring on those at highest risk. This is one monitoring technique we seldom see used outside of the anesthesia setting. If expanded into other areas, it may require purchase of additional equipment.