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Addressing the HCAHPS Domains: Communication about Medications and Pain Management
What was the challenge, opportunity or issue faced?
Through the Joint Collaborative Practice Group*, the Mary H. Hodges Joint Replacement Center inpatient unit reviewed its unit-specific H-CAHPS patient experience survey scores and looked for any lower-scoring items. Our H-CAHPS scores on the unit were very good and mostly at the 90th percentile nationwide; however, we received average scores on the Communication about Medications and Pain Management domains. Two questions were the cause. We would routinely score at or above the 90th percentile for half the domains: "always communicating what the new medication is for” and "staff always being sensitive to patients’ pain and doing everything we can to manage it.” However, we would receive low scores on the other half of the domains: "always communicating about the side effects” (25th percentile) and "pain always well controlled (25th percentile). We were also having frequent call lights from our patients with the common request of asking for pain medication and wanting to know when their next dose could be given.
*The Mary H. Hodges Joint Replacement Center/2 North Leadership team meets monthly to address issues and brainstorm fixes. Different processes are suggested, reviewed for feasibility, implemented and reviewed for success. This group is called the Joint Collaborative Practice Group.
What did they do to address it?
To better communicate with the patient about what to expect, to reduce their anxiety and to involve them in their care, we developed a comprehensive, multi-disciplinary approach to improve patient-perceived pain management and communication about medication side effects.
For pain management:
Dr. William Wallace, Medical Director of the Center, worked closely with the surgeons and anesthesiologists to determine what medications caused unwanted side effects, had poor tolerance and ineffective management. Through their collaborative effort, they discontinued use of Patient Control Analgesia (PCA) pumps and began using long-acting and shorter-acting medication by mouth. This new regimen proved to provide more consistent pain management and improved patient satisfaction. Also, the mandatory pre-operative Joint Class, taught by Program Manager Kristie Winters, was updated to include a strong section on pain management with an emphasis on patient- and family-centered care. Patients are empowered in the class and encouraged to actively participate in their pain management regimen. On the inpatient units, Nurse Manager Jackie Bookwalter implemented the use of a pain poster for each patient’s room. The nurse writes in the name of the medication, the time the last dose was given and the time the next dose is due. The nurses update the poster with each given pain medication. This allows the patient to know the timeframe and be mentally prepared to wait for the next dose. If they cannot wait, they are encouraged to use the call light so the nursing staff can contact the physician for further evaluation.
For side effects:
The hospital’s Pharmacy nurse educator educates patients regarding any new medications. Led by Edgar Gonzalez, PharmD, the educator changed her wording to emphasize side effects and began using highlighter on the papers she gives patients so they can easily find the side effects. Also, when the Pharmacy Nurse Educator is not available, she notifies the Joint Center leadership team. This allows the nurses the opportunity to seamlessly pick up the education. The Nurse Manager implemented the use of a side effects poster. The poster was placed in each room. It instructs the patient to be involved with their care and ask questions about their medication. We encourage the patient to ask if their nurse doesn’t explain side effects to them. This allows the patient to become more involved in their care and allows them to develop a rapport and to establish trust with the nurse. We also educated the nurses on the safety of patients knowing their side effects and we pre-printed the most commonly used drug education pamphlets and placed them in the medication room for the nurses to have easy access while preparing their medications.
What were the outcomes?
Our side effect scores became not only the best practice of the hospital, but also improved from the 25th to the 90th percentile nationally. Our pain well-controlled scores improved from the 25th to the 75th percentile nationally, just two percentage points below the 90th percentile. In addition to these two focused improvements, we saw an increase in our H-CAHPS overall rating top box score of an outstanding 21%! The unit’s overall rating score was the best practice for our facility and in the top 10% nationally, surpassing our 90th percentile goal. Our call light frequency decreased and the patients and the nurses were more in tune to when the next dose of pain medications were due. Furthermore, the patients were less apprehensive and anxious for the next dose because they knew when it could be given.
About Cabell Huntington Hospital
Cabell Huntington Hospital is a 313-bed major teaching hospital with a Level II Joint Trauma Center located in Huntington, West Virginia. The Total Hip and Knee Replacement Program received Disease-Specific Certification through The Joint Commission for both total hip replacement and total knee replacement November 9, 2010. HealthGrades has named Cabell Huntington Hospital one of "America’s 100 Best Hospitals for Joint Replacement.” Additionally, Cabell Huntington Hospital and the Department of Orthopedic Surgery at the Marshall University Joan C. Edwards School of Medicine are ranked #1 in West Virginia for overall orthopedic services and joint replacement, according to the 11th Annual HealthGrades Hospital Quality in America Study and #1 in West Virginia and the Tri-State Area for Major Orthopedic Surgery, Spinal Surgery and Joint Replacement by CareChex, the hospital quality ratings service of The Delta Group.