Background Understanding the effect of analgesia on pain helps guide management (Jenson, 2003). This recognition led to the creation of pain assessment tools (Hølen, Hjermstad, Loge, Fayers, et al., 2006; Hjermstad, Gibbins, Haugen, Caraceni et al., 2008). PIC completion at the hospice was low. Staff reported a number of reasons for this, one being the format of the PIC chart.

Aim Improve PIC completion in a hospice in-patient unit setting.

Method A quality improvement approach using a series of Plan, Do, Study, Act (PDSA) cycles was undertaken (Jones, Vaux & Olsson-Brown, 2019; Taylor, McNicholas, Nicolay, Darzi et al., 2014). A baseline measure was established of PIC for 70 analgesic medications prescribed to seven patients (10/patient). Two PDSA cycles were then undertaken and PICs reviewed.

Results At baseline, 10 out of 70 medications were correctly completed on the PIC (14%). Altering the PIC allowed more space for writing details and more room for multiple interventions to be documented on a single PIC sheet. After PDSA cycle 1, involving 15 PIC, completion increased to 27% (41/150). Further PIC re-design aimed at increasing the efficiency with more tick box options instead of written descriptions. Following PDSA cycle 2, involving 8 PIC, completion increased further to 36% (29/80). Across both PDSA cycles, it was apparent that PIC completion was much lower for patients dying compared with non-dying (11% vs. 46.5%).

Staff feedback indicated time constraint was the predominant barrier as well as PICs lacking prompts for recognition of non-verbal signs, therefore less useful for unconscious or dying patients.

Conclusion Although PIC completion rate improved with increasing chart efficiency (as feedback indicated time was the most limiting factor), we did not see the overall improvement in PIC completion that we hoped for. However, low levels of PIC completion are not necessarily indicative of poor pain management and we were reassured that hospice staff demonstrated awareness of medication efficacy in their daily practice. Our results have generated significant questions and further work is necessary. Recommendations include the addition of non-verbal signs to the PICs to specifically improve PIC completion for dying patients and the qualitative investigation of staff perception of PIC completion.