Ann Arbor, Michigan
Elevating Pain Management Strategies to Improve Patient Outcomes

Pain management in hospitals is a continuing challenge across the United States. Despite the creation of standards for the treatment of pain by The Joint Commission in 1999, gaps remain in the assessment of pain, ensuring use of the most appropriate medications, minimization of side effects, monitoring of therapy effectiveness, and improvement in patient outcomes and satisfaction.

At the University of Michigan Hospitals and Health System (UMHS), an institution-wide initiative was undertaken to review and improve strategies for pain management. This multidisciplinary team-driven initiative focused on improvements in treating pain effectively and safely while increasing standardization across the institution. This stemmed from two reviews: an event review of 33 patients who were unresponsive after being given opioid-type pain medications and a review of the use of the opioid antidote naloxone in the hospital during a 2.5-year period.

Over a 4-year period, the pharmacy medication safety officer and the pediatric safety coordinator led the implementation of the initiative, which included:
 
1. Developing standardized orders for patient-controlled pain treatment for those who had never been exposed to opioids before, were opioid tolerant or highly tolerant.
2. Creating systems for physicians to order pain control medications, based on equivalent doses of morphine, using  computerized technology.
3. Revising the list of absolute maximum doses for all opioid-type pain medications and sedatives.
4. Standardizing  solutions for medications given through the epidural routefor adult and pediatric patients.
5. Replacing naloxone for the treatment of itching with the alternatives ondansetron and nalbuphine.
6. Including a calculator in the electronic medication administration record to track the total amount of acetaminophen given to a patient on a daily basis.

This initiative has resulted in the improved safety and quality of pain management across the UMHS. There was an overall improvement in patient satisfaction scores, with increases from 80 percent to 86 percent. Changing the team system so that the inpatient care team was responsible for ordering patient-controlled pain medications resulted in a 10-fold decrease in acute pain consults. Naloxone administration for respiratory depression decreased from 34 cases in 2007 to 3 cases in 2010. Patients are no longer given acetaminophen doses greater than the recommended daily amount. The types of available epidural solutions decreased from 20 to 7 over the course of the initiative.  The UMHS continuously reviews all opioid related adverse events to improve medication safety.