Matching Interventions to Barriers in Pain Management

1. Matching Interventions to Barriers in Pain Management Ruth Cornish Program Manager

2. National Institute of Clinical Studies Role: To improve health care by helping close important gaps betweenbest available evidence andcurrent clinical practice

3. Whatweknow Whatwedo

4. Acknowledgements • Prof. Sanchia Aranda • NICS advisors • Deb Gordon & June Dahl (Wisconsin pain group) • Pilot hospital teams

5. Pilot hospitals Royal Brisbane Charles Gairdner Newcastle Mater Westmead Royal Perth FlindersRoyal Adelaide Peter Mac

6. Background www.nicsl.com.au

7. Aims • To improve the identification of patients with pain • To improve the day-to-day management of pain for patients with cancer • To integrate effective cancer pain management into the core business of hospitals

8. Barriers - Institutional • Lack of institutional commitment • Poor visibility of the problem • Professional territorial issues • Unclear lines of responsibility • Lack of practical tools & policies

9. Barriers – Clinicians • Attitudes & beliefs of staff • No routine pain assessment • Under-estimation of patients’ pain • Analgesia misconceptions • Prescribing & administration inconsistencies • Inadequate knowledge and education

10. Barriers – Patients • Inevitability of pain • Stoicism • Analgesia fears & misconceptions • Being a “good” patient • Distracting from treatment • Trade-offs: analgesics & side effects

11. Where to start?

12. Matchinginterventions to barriers

13. Lack of knowledge Educational courses Evidence based guidelines Decision aids Beliefs/Attitudes Peer influence Opinion leaders Lack of motivation Incentives / sanctions Perception-reality mismatch Audit & feedback Reminders Systems of care Process redesign Generic Principle

14. Institutional • Lack of institutional commitment • Executive champions • Peer hospitals? • Poor visibility of the problem • Audit & feedback to executive • We have a problem!

15. Institutional • Professional territorial issues • get everyone involved • multiple champions eg. Disciplines Nursing Medicine Pharmacy Quality/safety Departments Pain Palliative care Medical/Surgical Quality/safety

17. Clinical • Inadequate knowledge, education • needs analyses useful • don’t expect attendance at special meetings • use existing meetings opportunistically • include in orientation, rounds, intranet • nursing competency standards

18. Clinical • Attitudes and beliefs • Opinion leaders • Clinical champions • Peers

19. Clinical • No routine assessment • documented pain scores on vital sign chart • reminders • audit & feedback essential

20. Clinical • Prescribing inconsistencies • guidelines and decision aids at point of prescribing • equi-analgesia cards • standardised prescribing

21. Patient • Inevitability of pain; stoicism; being a "good" patient • "your pain is important to us" • organisation mission statement • hospital admission/discharge information includes pain management • ward posters

22. Patient • Distracting from treatment • "your pain is important to us" • involve patient in their own pain management • prompts to discussion

23. Patient • Analgesia fears, misconceptions (particularly addiction) • starting morphine is a "threatening procedure" for cancer patients • information for patients & families

24. Matchinginterventions to barriers

25. Begins with a sound analysis of barriers