Improving Documentation of Pain and Constipation Management Within the Cancer Center of a Large Urban Academic Hospital

Abstract

PURPOSE: Pain and constipation are common among patients with cancer and remain inadequately controlled in many. The Quality Oncology Practice Initiative assessment of pain and constipation at the Georgia Cancer Center for Excellence at Grady Health System identified documentation to be below benchmark levels. A quality improvement initiative to improve pain and constipation management was conducted. METHODS: Given the low baseline documentation rates for pain (60%) and constipation (20%), we aimed for an increase of 20 percentage points within 1 year. On the basis of cause-and-effect analysis and provider questionnaires to understand fully the causal factors, our multidisciplinary team developed a new provider note template to integrate nurse’s assessment of pain and constipation into the provider’s documentation. A new order panel was developed in the electronic medical record to link appropriate orders with the pain and constipation plan. RESULTS: The integration of the initial nursing assessment into the provider note template increased pain score documentation from 66.7% to 100% ( P < .01), and the pain management plan improved from 65.3% to 86.4% ( P = .06). Similarly, constipation assessment documentation improved from 20.4% to 100% ( P < .01), and a documented constipation plan improved accordingly from 11.2% to 29.1% ( P < .01). As a result of this intervention, pain control at the third clinic visit improved from 61.5% to 86.8% ( P < .01). Emergency department visits related to pain and constipation decreased (16.2% to 14.9%; P = .19), and hospitalizations marginally increased (1.6% to 3.6%) during the study period ( P =.28). CONCLUSION: A standardized visit template and hardwired assessment of pain and constipation exceeded the goal for improvement in documentation and positively affected outcomes.

Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

“…Ten studies utilized EHR modifications as one of the strategies to improve nursing documentation (Bruylands et al, 2013; Chineke et al, 2020; Esper & Walker, 2015; Gerdtz et al, 2013; Hom et al, 2019; Jacobson et al, 2016; Kamath et al, 2011; Nielsen et al, 2014; Sandau et al, 2015; Tejedor et al, 2013). Seven of these studies had a final compliance rate ≥ 70% (Chineke et al, 2020; Esper & Walker, 2015; Hom et al, 2019; Jacobson et al, 2016; Kamath et al, 2011; Nielsen et al, 2014; Tejedor et al, 2013). Prompts were used in four of the studies (Chineke et al, 2020; Hom et al, 2019; Kamath et al, 2011; Sandau et al, 2015), and except for Sandau et al (2015) they all had a final compliance of ≥ 80%.…”

“…Seven of these studies had a final compliance rate ≥ 70% (Chineke et al, 2020; Esper & Walker, 2015; Hom et al, 2019; Jacobson et al, 2016; Kamath et al, 2011; Nielsen et al, 2014; Tejedor et al, 2013). Prompts were used in four of the studies (Chineke et al, 2020; Hom et al, 2019; Kamath et al, 2011; Sandau et al, 2015), and except for Sandau et al (2015) they all had a final compliance of ≥ 80%.…”

“…Thirty two studies used new forms as one of their strategies for improving nursing documentation (Aparanji et al, 2018; Björvell et al, 2002; Bono, 1992; Cahill et al, 2011; Chineke et al, 2020; Christie, 1993; Dahlstrom et al, 2011; de Rond et al, 2000; Dehghan et al, 2015; Elliott et al, 2017; Ellis et al, 2007; Enright et al, 2015; Florin et al, 2005; Förberg et al, 2012; Gerdtz et al, 2013; Gordon et al, 2008; Hayter & Schaper, 2015; Higuchi et al, 1999; Hospodar, 2007; Hübner et al, 2015; Kamath et al, 2011; Karp et al, 2019; Khresheh & Barclay, 2008; Mansfield et al, 2001; Mitchell et al, 2010; Nomura et al, 2018; Nøst et al, 2017; O’Connor et al, 2014; Stewart et al, 2009; Stocki et al, 2018; Thoroddsen & Ehnfors, 2007; Unaka et al, 2017). Seventeen of the 32 studies had a final compliance rate ≥ 70%.…”

“…It should be noted that although Larrabee et al (2001) had a final compliance rate of 84.2%, the improvement was 0.2%. Ten studies utilized EHR modifications as one of the strat-egies to improve nursing documentation (Bruylands et al, 2013;Chineke et al, 2020;Esper & Walker, 2015;Gerdtz et al, 2013;Hom et al, 2019;Jacobson et al, 2016;Kamath et al, 2011;Nielsen et al, 2014;Sandau et al, 2015;Tejedor et al, 2013). Seven of these studies had a final compliance rate ≥ 70% (Chineke et al, 2020;Esper & Walker, 2015;Hom et al, 2019;Jacobson et al, 2016;Kamath et al, 2011;Nielsen et al, 2014;Tejedor et al, 2013).…”

Addressing Issues of Cancer Disparities, Equity, and Inclusion Through Systemized Quality Improvement

“…Furthermore, participant projects published in the oncology literature report impactful changes in delivery of cancer care at their local institutions. 14,15 On the basis of data from the evaluation, the Niarchos Foundation provided funds for an additional 10 practices to participate in a similar program. The current practices completed QTP at the end of 2020, and the entire grant program will run through 2023.…”