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Pain Management: A Quality and Safety Perspective

Pain Management: A Quality and Safety Perspective. Lisa G. Green, MSN, RN, AOCN Nurse Educator, Nursing Professional Practice and Education. Objectives. Discuss the magnitude of the cancer pain problem Assure pain is consistently assessed in a comprehensive manner

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Pain Management: A Quality and Safety Perspective

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  1. Pain Management:A Quality and Safety Perspective Lisa G. Green, MSN, RN, AOCN Nurse Educator, Nursing Professional Practice and Education

  2. Objectives Discuss the magnitude of the cancer pain problem Assure pain is consistently assessed in a comprehensive manner Explore interventions that meet evidenced based guidelines for the safe care and management of patients

  3. What is Pain? “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” World Health Organization and the International Association for the Study of Pain

  4. Cancer Pain Facts • Magnitude of the problem • World Health Organization (WHO) • International Association Study Pain (IASP) • Other expert committees • Incidence • 50% Early stages • 75% Advanced cancer • 33% Cancer survivors International Association for the Study of Pain, 2009

  5. Cancer Pain Facts • Requires more aggressive treatment; patients live longer, typically have “chronic disease”

  6. Etiology: Cancer Pain • 60%+ Tumor-related pain • Soft tissue • Bone • Visceral • 20%+ Treatment-related pain • Surgery • Chemotherapy • Radiation Is the cure worse than the disease?? Quality of Life

  7. Barriers: Pain Management • Patient- Access to care and resources, cost of medications and treatment, cultural issues, not burdening family, lack of knowledge, fear of cancer spread, fear of addiction • Provider- Poor assessment, lack of education, lack of resources, fear of addiction, reliant upon subjective reporting, time consuming • System/Bureaucratic – Not a priority issue, lack of funding, clinical specialists, research, access to resources

  8. Pain Management: South America • Revise the curriculum in medical schools addressing the scientific basis of QOL assessment • Prioritize and increase emphasis on clinical pharmacology • Address symptom control and end of life issues • Nervi, F., Guerrero, M., Reyes, M., etal. Symptom control and palliative care in Chile. Journal of Pain and Palliative Care Pharmacotherapy (JPPCP), 2003: 17: 13-22.

  9. Components: Comprehensive Pain

  10. Comprehensive Pain Assessment Q U A L I T Y • What does it look like? • How often is it done? • Is there ongoing assessment and follow-up? • How is the pain being treated? • Is it documented? • Are there available resources? Q U A L I T Y

  11. “If we cannot assess pain, we will never be able to relieve pain” Betty R. Ferrell, PhD, FAAN City of Hope, Duarte, CA

  12. Comprehensive Pain Assessment • Pain • For each site of pain determine type of pain (Nociceptivevs Neuropathic) and intensity level • Evaluate medical history • Physical examination • Function • Activities of daily living • Psychosocial Issues • Personalized Pain Goal

  13. Assessing Pain • Categories of Pain • Acute Pain • Chronic Pain • Combination • Types of Physical Pain: • Nociceptive • Somatic- arises from musculoskeletal • Visceral- arises from visceral organs • Neuropathic Determining the type of pain syndrome(s) the patient is experiencing is an indispensable part of determining the most effective treatment plan.

  14. Neuropathic Pain: Characteristics • Quality: often burning, numbing, shooting; or dull, aching, throbbing • Intensity: mild to excruciating and unresponsive • Distribution: Often in distribution of a nerve, plexus, root, or cord • Temporal pattern: May be constant, lancinating, or both • Exacerbated by traction or pressure on affected neural structures • Relievedby rest, counter-irritation Adapted from Katz. Clin J Pain. 2000;16(2 suppl):S41-S48.

  15. Pain Intensity Scales Notify doctor for pain rating >=4

  16. Pain Intensity Scales

  17. Pharmacologic Interventions: Pain • Opioids cornerstone of treatment • PO if possible • Intravenous • Transdermal • Adjuvant medications • Antidepressants • Antiepileptics • Muscle relaxants • Corticosteriods • Pyschostimulants

  18. World Health Organization (WHO) Cancer Pain Relief and Palliative Care, Geneva, WHO, 1990, p9.

  19. Equianalgesic Dosing • PO opioids can produce the same degree of analgesia as IV- Only 1/3 of the dose of po morphine enters systemic circulation due to the first pass effect (IV and transdermal dosing bypass) • Morphine equivalent daily dose (MEDD)- Current opioid regimen converted to the daily oral morphine equivalent • Allows comparison of a patient’s progress over time, and with different opioids • Enables more accurate and smoother rotation to another opioid • Allows comparison between patients • Facilitates communication between physicians and other providers

  20. Assess Success • Talk to the patient • Evaluate • Pain Intensity: 0----------------10 • Pain Relief: 0%-----------------100% • Pain Control: • Excellent, Good, Fair, Poor, None • Satisfaction: 0------------------10 • Interest for better pain control: Yes No • What component of pain improved? • Side Effects: tolerable or intolerable? • Did side effects occur and resolve?

  21. Quality Assessment: Pain • Patients perception of pain • Patients satisfaction of pain management • “Real time” satisfaction vs. post hospitalization • Avoidance of adverse events • Over-sedation • Respiratory depression

  22. Risk: Opioid Naïve Patient • Experience sedation at beginning of therapy and with significant increases • Sedation assessment vital to prevent respiratory depression • Trending vital signs • Hourly and every 2 hours for 1st 24 hours

  23. Goal: Effective Analgesia and Avoidance of Adverse Effects ANALGESIA SEDATION RESPIRATORY DEPRESSION (Hagle, M.E., Lehr, V.T., Brubakken, K. & Shippee, 2004; Zimmerman, P.G. 2010)

  24. Sources of Evidence • American Society for Pain Management Nurses Core Curriculum • American Pain Society • American Society of Anesthesiologists • Joint Commission • Evidence-based literature

  25. Adverse Events: Safe use of Opioids • Lack of knowledge about potency differences among opioids • Improper prescribing and administrations of multiple opioids and modalities of opioid administration • Inadequate monitoring on patients on opioids

  26. What Does Our Data Show? • Overall doing a great job • Low rates of adverse events • Vulnerable areas due to: • Volume • ~250,000 doses / 6 month period • ~12,314 PCA doses/yr • ~1700 PCEA doses/yr • ~ 650 doses per day • Increase use of PCA in medical areas • Patients receiving multiple opioid potentiating meds • Majority adverse events involve: • 1st 24 hours, initiation of therapy, during titration, unit to unit transfer, change in dose/concentration - Increase in Naloxone administration (20%)

  27. Quality Management: Patient Safety and Care • Instituted Interdisciplinary Pain PACT • Institutional policy • Standardized doses and order sets • Standardized pharmacy compounding • Standardization of pain documentation • PCA- “Smart Pumps” • Instituted mandatory EtCO2 monitoring with all PCA and PCEA analgesia

  28. Interdisciplinary Pain PACT • Nursing Practice Congress • Instituted Pain Pact 2004 • Interdisciplinary • Nurses • Physicians • Anesthesiologists • Pharmacists • Acute pain • Chronic pain • Palliative and supportive care

  29. Standardization: Order Sets,Doses, and Compounding • All physician orders on pre-printed order sets • Multiple safety features • “Tallman lettering” • Standardized concentrations • Morphine doses for patient populations • Pediatric: 1mg:1cc • Adult: 5 mg:1cc

  30. Order Set : Pain Management Pain Management Safety Feature TALLman Lettering Safety Intervention

  31. Standardization: Pain Documentation • To assure pain is consistently assessed and documented • Replacement of paper process with computerized electronic pain documentation • Clearly define when and where to document pain assessments and reassessments • Provides a permanent record ALL can view • Every healthcare provider is able to obtain and trend the pain management of their patients

  32. Patient Controlled Analgesia (PCA) • PCA Smart Pumps • “Hard and Soft” limits • Mandatory End Tidal Capnography (EtCO2) monitoring • Evidence supports close monitoring by nurses enhances effectiveness of analgesia and patient safety • Reduce source of potential errors and over-sedation

  33. Conclusions • Pain is: • Physiology complex • Multi-factorial and influenced by the individual’s perception experiencing the pain • Impacted by personal beliefs • Nurses: • Pivotal for effective, quality pain management • Have the most interaction and strongest connection with patient and family • Continually educating and insist that pain control issues be addressed in a timely fashion

  34. References Breivik, H., Borchgrevink, P. C., Allen, S. M., Rosseland, L. A., Romundstad, L., & Breivik Hals, E. K. et al. (2008). Assessment of pain. British Journal of Anaesthesia, 101(1), 17-24. Retrieved from http://bja.oxfordjournals.org/cgi/content/abstract/101/1/17 Camp-Sorrell, D. and Hawkins, R.A. (Eds). Clinical Manual for the Oncology Advanced Practice Nurse, 2nd. Ed.(2006) Oncology Nursing Society, Pittsburgh, PA. Choen, M, Williams, L, Knight, P, Snider, J, Hanzik, K, Fisch, M. Symptom masquerade: understanding the meaning of symptoms. Support Care Cancer (2004) Esper, P. & Kuebler, K.K. (Eds). Palliative Practices from A-Z for the Bedside Clinician,2nd Ed. (2008). Oncology Nursing Society, Pittsburgh, PA. Ferrell, B, Levy, M, Paice, J. Managing Pain from Advanced Cancer in the Palliative Care Setting, Clinical Journal of Oncology Nursing, Vol 12, 4. (2008). Fisch, M.J. & Bruera, E., (Eds), Handbook of Advanced Cancer Care, pages 341-360. (2003). Cambridge University Press, New York,NY

  35. References Henke Yarbro, C., Hansen, Frogge, M. & Goodman, M.(Eds) Cancer Symptom Management, 3rd Ed. pages 77-95.(2004) Jones and Bartlett Publishers, Sudbury, MA. IASP. (1979). Pain Terms: a list of definitions and notes on usage. Pain, 6, 249-252. McCaffery, M., & Beebe, A. (1999). Pain: Clinical Manual for Nursing Practice (2nd ed.). St Louis: Mosby. National Cancer Institute, Pain Assessment (2008) www.cancer.gov Scottish Intercollegiate Guidelines Network. Control of Pain in Patients with Cancer: Section 3 Assessment of pain. Retrieved 8/2008 www.sign.ac.uk. Smith, N. Patients in Pain – Part 1. Discoveries in Assessing and managing comfort. White Papers. NCR Picker, (2008) Universal Pain Assessment Tool. http://www.anes.ucla.edu/pain/FacesScale2.jpg van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol 2007;18:1437–49.

  36. References/ Chile • Nervi, F., Guerrero, M., Reyes, M., etal. Symptom control and palliative care in Chile. Journal of Pain and Palliative Care Pharmacotherapy (JPPCP), 2003: 17: 13-22. • Pain and policy studies group, WHO collaborating center for policy and communications in cancer care, University of Wisconsin Comprehensive Cancer Center, Madison, Wisconsin. Availability of opioid analgesics in Latin America and the World, prepared for the 1st Congress of the Latin American Association of Palliative Care, March 2002. • The Joint Commission: Sentinel Event Alert. Safe use of opioids in hospitals., Issue 49, August 8, 2012. • Thomas-Lloyd, A.R., (2000) Santiago, Chile 2000, The control of pain in children, The control of pain in children- why treat pain? Retrieved from http:// dialspace.dial.pipex.com/town/park/ae069/chile.htm • www.who/int • www.isap-pain.org

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