J. Hwang1, S. E. De Palm2, M. Massimiani2, E. LaMura2, K. Sigafus2, S. M. Nazarian1 2Hospital Of The University Of Pennsylvania,Medical-Surgical Specialty Nursing,Philadelphia, PA, USA 1University Of Pennsylvania,Department Of Surgery, Division Of Transplant Surgery,Philadelphia, PA, USA
Introduction:
A patient’s impression of the quality of their care is strongly influenced by their pain management. Quality of pain management is a point of emphasis in health quality evaluations: 3 of the 25 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions relate to pain. A frequent patient concern and topic of Press Ganey comments is long wait times for pain medication. We sought to understand the process of pro re nata (PRN) pain medication administration, and identify potential opportunities for safe process improvement.
Methods:
A process map for pain medication administration was created. Time points along the map available from the electronic medical record were obtained for pain and non-pain PRN medications. The smartphone app Emerald Timestamp (Emerald Sequoia, LLC) was used while shadowing registered nurses (RNs) to confirm electronically timestamped data, obtain time points for non-timestamped data, and record activity between time points. The total time from RN notification to medication administration was calculated. Using two-tailed unequal variances t-tests, times were compared between pain and non-pain PRN medications.
Results:
A total of 21 PRN medication events were observed, two of which were determined to be outliers and removed from further analysis. Patients did not always request pain medications directly from their RN. Visitors, certified nurse assistants (CNAs) and other care providers served as messengers. CNAs took 2.3 minutes on average (N = 11) to relay a medication request to an RN. RNs also preemptively asked if the patient would like pain medication. Patients waited an average of 37.6 minutes for all PRN medications (N = 19), with a significant difference between PRN pain (44.1 minutes, N = 15) and non-pain (13.0 minutes, N = 4) medications, P = 0.04. The five longest wait times for pain medication were due to dosing restrictions on frequency, including the longest wait of 308 minutes. When the instances of delay due to frequency restriction were eliminated, there was no significant difference between pain (N = 11) and non-pain (N = 4) PRN medication administration (25.3 vs. 13.0 minutes respectively, P = 0.53).
Conclusion:
The process of PRN pain medication administration includes many steps. The main cause for pain medication delay was restriction on frequency. Medication administration did not appear to take longer for pain medications compared to non-pain, although numbers may have been too small to detect a significant difference. Based on these preliminary findings, we have expanded data collection and will soon begin the analysis of multiple years of hard timestamped data on the factors affecting the administration of PRN data (bolded boxes in the figure).
