PatPop

Q: Is there any specific definition of a "Major surgical procedure" for this study?

A: No, just use your common sense. Probably doesn’t make sense to throw in biopsies or minor procedures with colectomies. At the same time it’s perfectly OK to sample mastectomy, thyroidectomies, ortho cases, ABD surgeries…the idea is to sample an average group of your postoperative patients.

Q: Do I use the same patients for the Medical Record Audit & the Patient Survey? Can I audit more charts than patients who complete the survey?

A: It is recommended, but not necessary that you use the same patients for both the chart audit and patient survey. You can then track the correlation of satisfaction/dissatisfaction with the methods used, e.g., what kind of analgesic regimen and assessments were recorded. It makes much more sense to get a comprehensive look at patient experience and staff practices on the same group of patients. However, you are certainly welcome to do more chart audits (or patient surveys) as you wish.

Q: Should we include patients staying 24 hours? Should/Can we include the Caesarean Population? Can we survey ambulatory care patients?

A: You can include whatever population you want as long as you can identify and indicate big differences (like medical cancer versus surgical non-cancer groups or the ortho unit versus the peds post-op unit). Someone else called me the other day and they are going to survey outpatients in the home through their home care nurses (these are post-op patients who go home the same or next day and get a nursing visit). Points of transition in care like return to home are critical times to look at pain management. We recommend surveying the first 24 hours after operation but you should do what makes sense for the group of patients you are targeting. Try to set up a process that makes it easy to do longitudinal comparisons.

Q: Does an "Intermediate Care Unit” (a monitored bed step down unit) classify as a "non-ICU nursing unit”?

A: Yes, intermediate care or telemetry patients are fine to include in the survey. We just wanted to have folks steer away from intubated, sedated, critically ill patients who could not complete a survey in their current status. Perhaps the most common population that might be a cross over are CABG patients (coronary artery bypass patients) who typically spend part of their first 24 hours in an ICU. Staff should audit the first 24 hours of care after return to a non-ICU unit and if they are surveyed it should be done within 72 hours of operation to assess their experience (or remembrance of their experience) of the first 24 hours.

Q: Our patients go home before 24 hours have elapsed from their procedure. There are no nurses at the clinics in the villages where the patients live. If we send a patient survey home with the patient or family members, they may fill it out without fully comprehending the meaning of the 10-point pain scale (our facility has recently adopted a five-point scale using faces instead of numbers). Our pain management team would like to propose the following: 1) Modify the pain scale on the patient survey form to five faces scale, making the survey more culturally relevant and easier to understand; 2) Change some of the wording to make it easier for the patients to read and comprehend.

A: Yes, by all means please modify any and all parts of the data collection tools or methodology to fit your population that make sense. The purpose of the project is to stimulate the development of QI processes to improve pain management and provide some building blocks in the form of tools. We anticipate many institutions will modify their data collection process. We would still like you to share with us what you do and your data but modification are perfectly acceptable.

A: Absolutely. This can be done with relatively minor changes on the form by substituting a peds scale for the 0-10 scale. However, you will need to analyze these data separately or modify the access database, as it is currently set up for adult surveys.

A: Depends a little on how your hospital is organized and how you want to look at the data for internal and longitudinal comparisons. You may want to compare nursing units or you may want to compare practices across different surgical services. The forms are set up to use on all hospital patients, not just surgical patients so that you can compare surgical cancer, surgical non-cancer, medical non-cancer, and medical cancer.

Q: What criteria are you using to assess & manage pain in the unconscious/comatose/drug induced sedated patient?

A: Because pain is built into the ongoing assessment parameters in the documentation policy and standard it is our expectation that pain is assessed along with other things in an ongoing manner. Under these circumstances we teach and try to stress with our nurses a) use common sense (e.g., if you think the patient hurts they probably do), b) use behavioral/autonomic parameters that are available and individualized to the patient and situation as best you can (the critical care flow indicators to prompt assessment of grimace, moan, etc), and c) consider a trial of analgesic. I think we would all agree this is difficult situation and one that requires the art of nursing and application of preemptive analgesia.