A quality improvement intervention was effective in increasing hospice enrollment, pain assessment, nonpharmacologic pain treatment, and advance care planning discussions.

This study tests the association between residents' cognitive impairment and nursing homes' pain management practices. We used chart abstraction to collect data on 551 adults in six North Carolina nursing homes. From the standard data collected in the Minimum Data Set, 24% of residents experienced pain in the preceding week. Reports of pain decreased as cognitive abilities declined: nurses completing the Minimum Data Set reported pain prevalence of 34%, 31%, 24%, and 10%, respectively, for residents with no, mild, moderate, and severe cognitive impairment (P<0.001), demonstrating a "dose-response"-type result. Eighty percent of cognitively intact residents received pain medications, compared to 56% of residents with severe impairment (P<0.001). Cognitively impaired residents had fewer orders for scheduled pain medications than did their less cognitively impaired peers. Yet the presence of diagnoses likely to cause pain did not vary based on residents' cognitive status. We conclude that pain is underrecognized in nursing home residents with cognitive impairment and that cognitively impaired residents often have orders for "as needed" analgesics when scheduled medications would be more appropriate.

Dying nursing home residents need improved emotional and spiritual care, help with personal cleanliness, and treatment for pain. Efforts to improve end-of-life care in nursing homes should combine traditional palliative care services with increased attention to emotional symptoms and personal care services.

The objective of this study was to test whether a quality improvement intervention can improve pain management in nursing homes. Experts in quality improvement and clinical pain management provided nursing home staff leaders with feedback on pain quality indicator data, education in pain management, and technical assistance to apply the Plan-Do-Study-Act model of quality improvement. Trained abstractors completed structured chart audits at baseline and five months to capture quality indicator data related to pain assessment and treatment. Residents in pain who underwent pain assessments increased from 8% to 29% (P < 0.001). Residents receiving non-pharmacological pain treatments increased from 31% to 42% (P = 0.010), but pain medication use did not change. Among residents with daily moderate or excruciating pain, complete pain assessment was associated with increased probability of pain medication use. Quality improvement is a promising method to improve pain management in nursing homes.