THE WAY I SEE IT

One-size pain regs won't work

The JCAHO's new pain standards create more problems than they solve, charges the author.

By Councill Rudolph, MD
General Surgeon/Winchester, TN

Pain-management standards developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are well intentioned, but as wrongheaded as they can be.

The standards, which took effect January 2001, require that health care organizations:

• Make proper pain assessment and management both a patient right and a training priority

• Emphasize the quantitative aspects of pain

• Encourage systematic assessment

• Emphasize safe management

To assure compliance, JCAHO requires that doctors be overseen by supervisory personnel at every stage of patient care. The rationale? Among other things, a series of studies, reviewed by JCAHO, that showed that physicians' traditional practices resulted in mismanagement of participants' pain a high percent of the time. As a result, JCAHO experts recommended that a forceful and prescriptive program of pain management be initiated nationwide.

The effect of all this on doctors is disturbing. The standards, at least as interpreted by many hospitals, undermine physician authority, while dramatically increasing physician responsibility.

Pain management by the numbers

Like most other hospitals, the one I work in adopted measures to prepare for its JCAHO inspection.

Posters announcing a patient's right to pain relief were hung in every clinical room and by the front desk of the emergency department. Underneath the headline, the caption read, "No one should have to live with pain."

This message was reiterated to patients, first by the desk clerk (who also asked patients to sign written acknowledgments of the hospital's commitment to prompt pain relief) and then by the triage nurse.

"Are you now in pain or have you experienced pain within the past six months?" this nurse was required to ask new patients. Affirmative responses were followed by a series of 20 questions.

At this point, the nurse showed patients a plastic card with a series of numbered faces, ranging from smiling, to frowning, to crying. The higher the number, the more the distress. Once a patient selected the face representing his current state of pain, the number was recorded along with his vital signs.

If that number exceeded four (the maximum acceptable pain index at our hospital), physicians had to initiate steps to reduce it. Acceptable therapies included verbal soothing, physical therapy, or drugs. Therapies permitted at your hospital may be different.

Many of these changes are still in place. Some others—like the posters plastered everywhere—have been scaled back.

At our hospital, even patients who may be psychotic or addicted to drugs can't be discharged from either the recovery room or ED until their scores on this subjective scale reach four or less. Doctors who initiate a discharge prior to reaching this goal must explain their action to the hospital.

Perhaps this policy could work for terminal cancer patients. But most of the patients we see fall into one of three other categories: (1) patients who are not in pain and for whom pain management is, therefore, irrelevant; (2) patients who are in pain and for whom pain suppression is appropriate only once the proper diagnosis and treatment has taken place; and (3) patients who lie about pain in order to receive drugs.

In short, putting symptom management first, as our hospital attempted to do, is bad medical practice. Indeed, how did a symptom, in this case pain, become more significant than the disease causing it?

A call to arms for physicians

What can doctors do to register their frustration?

One approach is to contact the AMA or your state medical society. Two years ago, the Georgia delegation to the AMA's annual meeting introduced a resolution calling for the AMA to study "the efficacy to date of the new JCAHO standard . . . and identify who is responsible for its origins." The Arkansas delegation went further, condemning the standard and calling upon the AMA to "continue its work to preserve the sanctity of the physician-patient relationship."

In June 2002, the AMA's Council on Scientific Affairs responded to both resolutions, recommending that a multidisciplinary panel be created to "objectively study and evaluate the efficacy to date of the new JCAHO standards." Currently, that's where things stand.

At a minimum, we must urge the JCAHO to go back to the drawing board.

Our message is simple: The best hope for a very sick or injured patient in pain is not some remote credentialing body. It's the patient's physician.

What the JCAHO says

Editor's note: We showed a copy of Dr. Rudolph's article to the JCAHO. Here's the response by Richard S. Frankenstein, MD, chairman of the Standards and Survey Procedures Committee.

"Listen to the patient." This simple edict is at the heart of the evidence-based pain management standards introduced by JCAHO in 2001.

Pain is one of the most common reasons that patients seek medical care, yet it is often inadequately treated. The outdated and inaccurate view that pain is an inevitable part of health care must be set aside. Instead, we must recognize that appropriate pain management is good medicine because it results in faster clinical recovery, shorter lengths of stay, fewer readmissions, and improved quality of life.

JCAHO standards do not, however, dictate specifically how pain should be assessed or managed. Furthermore, they in no way interfere with the special relationship that exists between doctor and patient. The standards are designed to help caring physicians and the patients who depend on them by encouraging a systemic, organization-wide focus on the appropriate assessment and management of pain.

Councill Rudolph. The Way I See It: One-size pain regs won't work.

Medical Economics

Aug. 8, 2003;80:49.