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Pain management project: New standards begin Jan. 1

28 Oct 2018

Team has been working on compliance since May



By: Lydia Reid, MSN, BA, RN, CHRN, SCRN, senior regulatory specialist

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The Joint Commission issued new standards regarding pain management for hospitals starting Jan. 1. An interdisciplinary team has worked since May on compliance. (You may read the TJC standards here.) The project will be complete on Oct. 31. Key changes:

  • The Adult Pain Assessment policy has been renamed to “Pain Management” and has several revisions:
    • References to our Integrative Therapies Policy.
    • Information about resources and referrals for pain management needs.
    • Information about patients who may need increased monitoring.
  • Education rolling out to nursing staff includes:
    • Emphasis on the required pain screening/assessment for every patient including ED and inpatient.
    • Emphasis on educating patients/caregivers regarding pain and the use of opioids.
    • The pain content in the patient education section of Epic includes robust information regarding opioids.
  • Increased monitoring will be provided for patients at high risk for adverse outcomes due to the administration of analgesics and/or sedatives. These patients may include those receiving:
    • An epidural (see Epidural Analgesia for the Non-Laboring Adult Patient policy).
    • A PCA.
    • Sedation or general anesthesia (see Sedation Minimal Moderate Deep policy or the appropriate department policies such as post-op care for recovery).
  • Resources for pain management:
    • CHEC offers health screenings, classes on physical activity such as yoga and tai chi and cooking/nutrition. Call the Community Health Education Center at 503-814-2432.
    • Educational materials and resources for clinicians regarding pain management are available on the Pain Management SharePoint site. You can access this page from the Epic button under reference links. Click on “Pain Management Resources.” 

    pain mgmt standard

  • Providers caring for complex pain management patients have these resources available:
    • Consult to care management
    • Pain management pharmacist for consultation
    • Pain Clinic referral
    • Palliative care referral