9/9/2011. Agenda. Multi-Year Pain Prevalence Studies: Key To Changing A Hospital s Pain Management Culture And Practices?

Transcription

1 Multi-Year Pain Prevalence Studies: Key To Changing A Hospital s Pain Management Culture And Practices? Jason Sawyer, RN, BSc.N, MN Specialty Practitioner Acute Pain Service Jason.sawyer@sunnybrook.ca The most damaging phrase in the language is: 'It's always been done that way.' - Grace Murray Hopper Agenda Briefly outline current resources dedicated to pain mgmt at Sunnybrook Health Sciences Center Describe the process and evolution of conducting 5 pain prevalence studies in 6 years at a large teaching hospital Provide an overview of the results of these studies Discuss possible interpretations of the results Describe the evolution of the institutional response to the results Questions? 1

2 About Sunnybrook bed Veterans Hospital 1976 Canada s first stroke care unit 1976 Canada s first trauma program Currently 1212 beds 677 acute care beds Pain Mgmt Resources Acute Pain Service ~7200 pts/year 3.5 nurse practitioners/specialty practitioners Anesthesiology led Palliative Care consult team ~ 1000 pts/year 2 clinical nurse specialists Physician led Chronic pain clinic ~1300 pts/year 1 nurse co-ordinator Anesthesiology led Multimodal Analgesia 2

3 Why Pain Prevalence? Provide a snapshot of practice Quick (with sufficient resources) Local data Improve the quality of available data NRC-Picker In-Patient Pain Questions NRC Picker Data SHSC patients over 35 quarters When you had pain was it usually severe,moderate or mild? Pain Severe =1 Moderate = 2 Mild = pts over 35 quarters ( ) Do you think hospital staff did everything they could to control your pain? patients 34 quarters ( ) Overall, how much pain medicine did you get? = yes definitely 2= yes somewhat 3= no 1= not enough 2=right amount 3= too much 3

4 Conclusions Patients usually have moderate pain that trends toward severe However patients feel we are Doing our best Give enough medication 10 Local Efforts To Make Improvements Chart audits Pain mgmt in nursing orientation policies & procedures Preprinted ordersheets Increased APS staff 4

5 Thanks & Appreciation Sara Robinson Sandra Robinson Farida Roy Mona Sawhney Pat Daines Kali Stillos Paul Kaups Lynn Haslam Nursing Council Frances Flint Marg Blastorah Marko Katic Alex Kiss Prevalence Study Annual research ethics board approval Single day (4 hours) Utilized nursing council staff Manpower Engaging staff in research Dissemination of results Pain mgmt is a nursing sensitive outcome 5

6 Inclusion Criteria Exclusion Criteria Able to read/write English (or family member present to assist) Sign consent Admitted to a surgical unit or palliative care unit ICU patient Decline/inability to provide informed consent Admitted to medical unit (2008-present) Process-Helpful Hints Preparation Request/receive Nursing Council approval Ethics Approval Envelopes, stamps, photocopies, pens $$$$ Envelope stuffing Patient lists dedicated time (4 hours not quite enough) Pick up/drop off location Process for data collection Day of Study There will be no shows Variable enthusiasm Need detailed instructions Provide list of patients to be approached Constant circulation amongst units A unique issue will arise every year The easier the data collectors job is, the easier yours will be afterwards Evolution of Data Collection Year Demo graphics 2006 BPI McGill SLANNS Meds Preop Pain Post Discharge BPI & SLANNS PRN Meds Admin

7 Demographics 2007 (Yr 1) (n= 98) 2008 (Yr 2) (n=97) 2010 (Yr 3) (n=94) 2011 (Yr 4) (N= 83) Mean Age 62.7 (19-88) 63.2 (20-86) 60.4 (21-94) 62 (16-93) Gender (Male) 48% 55% 52% 54% Mean Days Postop 4.96 (0-33) (1-165) 6.96 (0-66) 7.44 (0-48) # pts followed by Acute Pain Service # pts followed by Palliative # pts followed by Chronic Pain 24 (24%) 23 (23%) 39 (41%) 23 (27.7%) Reasons Given For Not Participating (%) ( ) 1 1. No Reason 2. Refused 3. Off Unit 4. Too Tired 5. No Pain 6. Too Sick 7. Discharged 8. Confused 9. Too much Pain 10. Fresh Postop 11. Too Busy 12. Preop Pre-hospital Pain Were you having any pain at home prior to coming to the hospital? pts (68%) pts (64%) <1 wk 9 (14%) 12 (23.5%) >1 wk 3 mos 17 (26%) 6 (11.8%) 3 6 mos 7 (11%) 8 (15.7%) > 6 mos 32 (50%) 25 (49%) Mean VAS at Home 68.1 Range Range

8 Who Prescribed Your Pain Medications For You At Home? pts (67%) pts (49%) Primary Care Provider Self 6 10 Chronic Pain Clinic 3 0 Walk in Clinic 1 0 Physio 1 0 Other 0 11 Brief Pain Inventory Pain Scores & Level Of Pain Interference (114 pts) 2007 (98 pts) 2008 (99 pts) 2010 (94 pts) 2011 (83 pts) Current Pain Worst Pain Average Pain General Activity Mood Walking Relationships Sleep Enjoyment of life % of Pts Reporting 7/10 Pain & Pain Interference Current Pain Worst Pain Average Pain General Activity Mood Walk Relationships Sleep Enjoyment of Life 8

9 Neuropathic Pain at Time of Survey Based on S-LANSS Score pts (41%) pts (26%) % of Surgical Unit Patients Prescribed Different Analgesic Classes Acetaminophen NSAID/COX-2 Gabapentinoid OPIOID RTC OPIOID PRN only 30 patients not prescribed an NSAID/COX-2 had no contraindication 9 patients had a contraindication Interesting.. Patients Pain Right Now % of PRN Analgesic Administered in the Previous 12 Hours Pain Score N Mean SD 95% CI of Mean Lower & Upper Bound 0-mild pain % 19.5% 8.4% 16.5% Moderate pain % 24.7% 10.6% 28.1% Severe pain % 29.9% 8.5% 33.8% Total % 22.8% 11.7% 19.1% 9

10 Interesting.. Patients Average Pain % of PRN Analgesic Administered in the Previous 12 Hours Pain Score N Mean SD 95% CI of Mean Lower & Upper Bound 0-mild pain % 13.6% 5.7% 12.9% Moderate pain % 25.9% 11.4% 24.6% Severe pain % 27.5% 11% 31.6% Total % 22.7% 11.6% 19% Dissemination Internally to several clinical and leadership groups Publications Conferences 10

11 Evolution of Institutional Response Denial Anger Bargaining Acceptance What Did We Learn? Annual prevalence studies are lots of work but very rewarding Can build camaraderie amongst your fellow pain mgmt colleagues 1 year of data will not likely be enough to capture the attention of clinicians or executives 11

12 What Was Most Interesting? The high pain scores preop The prevalence of neuropathic pain The analgesic prescribing practices (particularly PRN s) The utilization of PRN opioids WE HAVE LOTS OF WORK TO DO We only have 5 snapshots Decrease the % of patients that report severe pain We only know what is happening on surgical/palliative care units We still don t know much about patient & staff perspective Further explore the prescribing/utilization of PRN analgesia Further explore the preoperative pain experience (especially in THR/TKA) Use this data as a springboard to innovating change at the corporate level & bedside Devils Advocate Do we have to make significant changes to practice or are we setting the bar? 12

13 The Payoff 3 year multidisciplinary strategic plan Implementation of best practice guidelines in 6 areas 1. Pain mgmt 2. Skin & wound care 3. Patient centered care/supporting families 4. Vascular access 5. Mobility 6. Managing high risk behaviors 13

14 in_and_supp.pdf lkit.pdf Are Multi-Year Pain Prevalence Studies The Key To Changing A Hospital s Pain Management Culture And Practices? MAYBE A tool to gain the attention of clinicians and administrators Will likely mean you are in charge of the next steps A tremendous amount of work Totally worth it! 14

15 The most damaging phrase in the language is: 'It's always been done that way.' - Grace Murray Hopper jason.sawyer@sunnybrook.ca 15