Implementing an Evidence-Based Functional Pain Assessment Scale in an Adult Inpatient Unit.

BACKGROUND: The focus on pain assessment using a single, one-dimension pain assessment scale can be problematic. Locally, challenges we faced with this were; a) pain was percieved as not being effectively managed, b) patients with chronic pain were not having their pain adequately controlled, and c) misconceptions and subsequent confusion between health care teams and patients related to what pain intensity scores mean to each individual. AIMS: The purpose of this paper is to describe an evidence-based practice project aiming at improving pain assessment through the implementation of a Functional Pain Scale (FPS) on an adult inpatient cardiothoracic unit. DESIGN: The Iowa Model-Revised and the Implementation Strategies for Evidence- Based Practice Guide served as the framework for this project. SETTING: Over an 18-month period at a academic tertiary medical center in the midwest. PARTICIPANTS/SUBJECTS: Staff and patients on an adult inpatient 48-bed medical and surgical cardiothoracic unit. METHODS: Following a synthesis of the evidence, implementation of the FPS required various strategies, such as, individualized patient and staff education, audit and feedback, a pain policy revision, and creating documentation in the electronic medical record. Evaluation of the FPS consisted of patient and staff surveys pre- and postimplementation to assess knowledge, attitudes, and behaviors. RESULTS: After the pilot period, over 75% of the patients preferred to use the FPS and almost all the patients found the scale easy to use. Nurses reported an increase in perception that pain documentation was complete, that the FPS allowed them to accurately document their patients' pain experience, and that their patients were well informed of their pain management plan. CONCLUSIONS: This project supports successful implementation of the FPS within nursing workflow. The goal of using the FPS is to change pain management discussions from an intensity reduction to meeting goals of care, aligning expectations, and creating common language among patients and providers.

Improving Outcomes in Patients Sent to the Emergency Department from Outpatient Providers: A Receiver-Driven Handoff Process Improvement.

BACKGROUND: Outpatient providers refer to emergency departments (EDs) due to findings requiring assessment beyond existing capabilities. However, poor communication surrounding these transitions may hinder safety and timeliness of emergency care. Receiver-driven handoff (RDH) is a process that helps ensure that all pertinent information is shared. This quality improvement project aimed to (1) improve knowledge of RDH, (2) increase satisfaction and perceptions surrounding RDH, (3) modify behaviors in relation to RDH, and (4) decrease referred patients leaving without being seen (LWBS). METHODS: The Iowa Model and Implementation Framework guided this evidence-based quality improvement project. A multidisciplinary team developed and implemented a standardized RDH process consisting of screening to determine whether a patient was referred to the ED, review of electronic health record (EHR), and use of EHR documentation. Process measures were collected via questionnaire pre- and postimplementation and were analyzed quantitatively. Outcome measures were trended by a statistical process control p-chart, which was developed to demonstrate changes in the percentage of patients who were referred to the ED from the outpatient setting and LWBS. RESULTS: The average response for the question "How satisfied are you with the handoff of patient information from referring clinic providers to the ED?" increased from 1.51 preintervention to 2.04 postintervention (p = 0.005). Respondents rated the information received during handoff higher postintervention (2.12 vs. 2.52, p = 0.04). Compliance with screening for referral to the ED was 84.0%. The proportion of patients LWBS after referral decreased by 6.2 percentage points (p < 0.001). CONCLUSION: Using RDH in conjunction with a standardized triage screening may improve quality of information shared during this vulnerable transition and may assist in reduction of referred patients LWBS. The RDH process should be adapted into everyday workflow to ensure sustainability and effectiveness.

Evidence-Based Pain Assessment in Nonverbal Palliative Care Patients.

BACKGROUND: Central to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering. AIMS: The purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients. DESIGN: The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks. SETTINGS: On a six-bed adult inpatient Palliative Care Unit (PCU). PARTICIPANTS/SUBJECTS: Nonverbal palliative care patients. METHODS: Evidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption. RESULTS: Nurses' attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores. CONCLUSIONS: MOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

Pain assessment & management decision-making in pediatric critical care.

PURPOSE: The aim of this study was to explore how nurses in the Pediatric Intensive Care Unit (PICU) reach their pain management decisions in children who are mechanically ventilated and chemically paralyzed. DESIGN AND METHODS: A qualitative descriptive design was used following a quantitative phase of a multi-method study. Eighteen PICU nurses participated in semi-structured interviews aiming at understanding how they assess pain and make management decisions. Content analysis was used to guide coding and generate themes. RESULTS: Three major themes were identified: 1) Assessment or cues that nurses use to trigger a pain assessment; 2) Mental models or patterns that nurses create to interpret cues to guide decision-making; 3) External factors that inhibit or facilitate decision-making. Overall, nurses rely on physiological cues to assess pain. From there, a large amount of variation exists on how nurses interpret those cues to make their pain management decision. External factors such as unit culture, perceived barriers and facilitators, and the nurse's experiences impacted how decisions are made. CONCLUSIONS: Variation exists in the mental models' nurses create to make their pain management decision in this population. Nurses reported confusion on pain and sedation scale selection and various documentation practices for pain assessment. "Assume pain present" was identified as a concept and documentation practice that may guide decisions; further research is needed. PRACTICE IMPLICATIONS: Development of clinician decision support tools that not only aid their understanding of reliable pain cues but also help create clear documentation practices may help nurses make pain management decisions.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation.

BACKGROUND: Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice. OBJECTIVES: To describe how PICU nurses are assessing and managing pain for children who require NMB. METHODS: A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither. RESULTS: A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent. CONCLUSIONS: These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Pediatric Pain Assessment in the Intensive Care Unit: An Evidence-Based Algorithm.

BACKGROUND: Conducting an adequate pain assessment in the Pediatric Intensive Care Unit (PICU) is multifactorial and complex due to the diversity of the population. It is critical that validated pain assessment methods are used appropriately and consistently to aid in evaluation of pain and pain management interventions. PURPOSE: The aim of this evidence-based practice project was to improve pain assessment practices in the PICU through a decision-support algorithm. DESIGN & METHODS: The Iowa Model-Revised was used to guide the development and implementation of an evidence-based decision algorithm. Pre- and postdata were collected via surveys (nursing knowledge and confidence) and documentation audits (nursing pain assessments). Various implementation strategies were used to facilitate the integration and sustainability of the algorithm in practice. RESULTS: The majority of survey items showed an increase in nursing knowledge and confidence. Audits of pain assessment documentation displayed an increase in appropriate pain assessment documentation related to a child's communicative ability. However, there is a need for reinfusion related to the documentation of sedation assessments. CONCLUSIONS: The use of an algorithm supported the ability of PICU nurses to critically consider and choose the pain assessment method most appropriate for the patient's condition. The algorithm promotes nursing clinical judgement, prioritizes pain management, and includes patients receiving sedation. The algorithm supports a comprehensive pain assessment in a difficult pediatric patient population. Future research is needed to strengthen and standardize the usage of terms "assume pain present" and "assume pain managed," and to also improve the overall feasibility and effectiveness of the algorithm.

Pain Assessment Practices in the Pediatric Intensive Care Unit.

PURPOSE: Pain assessment is the first step in managing pain; however, this can be challenging, particularly in settings such as the Pediatric Intensive Care Unit (PICU). This paper reports the current pain assessment practices from a study that was conducted describing the prevalence of pain, pain assessment, painful procedures, interventions, and characteristics of critically-ill children. Specifically, this paper addresses the child's communicative ability, pain scales, and characteristics of pain. DESIGN AND METHODS: The primary study was a cross-sectional, multi-site, descriptive design. Data from a 24-hour time period were collected from medical records and bedside nurses. RESULTS: Data were collected from the records of 220 children across 15 PICUs. The average number of pain assessments per child was 11.5 (SD 5.8, range 1-28). Seven behavioral scales and five self-report scales were used. There were times when no scale was used, "assume pain present" was recorded, or a sedation scale was documented. Twelve pain scales, including the target population, scoring, psychometric properties, and clinical utility are described. CONCLUSIONS: Results of this study indicate that a wide range of pain assessment tools are used, including behavioral scales for children unable to self-report. IMPLICATIONS: Foremost, the appropriate assessment method needs to be chosen for each child to manage pain. Knowledge of the criteria for the use of each pain assessment scale will help the clinician select the appropriate scale to use for each child. The practice of "assume pain present," as well as standardization of pain scales, and clinical support tools needs further investigation.

Pain in the Pediatric Intensive Care Unit: How and What Are We Doing?

BACKGROUND: Pain management in critically ill children is complex. Epidemiological research is needed to identify how often patients in pediatric intensive care units experience pain and the practices being used to lessen pain. OBJECTIVES: To describe pain assessment and intervention practices in pediatric intensive care units, determine the prevalence of pain and painful procedures, and identify characteristics of children with moderate to severe pain. METHODS: A 24-hour observational cohort study was conducted in 15 units. Nurses completed surveys regarding patients' communicative ability. Patients' records were reviewed for pain assessments, painful procedures, and pharmacologic and nonpharmacologic interventions. RESULTS: For the 220 patients in this study, pain was assessed a median (interquartile range) of 10 (7-13) times, usually with behavioral pain scales. Sixty-eight percent of patients received pharmacologic interventions and 44% received nonpharmacologic interventions. Fentanyl was the most common analgesic provided. Repositioning was the most common nonpharmacologic intervention. Forty-five percent of patients had pain and 24% had moderate to severe pain. Patients experienced a median (interquartile range) of 7 (2-15) painful procedures in 24 hours. More frequent pain assessments and pharmacologic interventions and the ability to communicate were associated with moderate to severe pain. No patient in the moderate to severe pain category received neuromuscular blockers. CONCLUSIONS: Critically ill children experience pain and multiple painful procedures daily. Assessment and intervention practices vary considerably. Research is needed to establish best practices for pain assessment in patients with limited communicative ability and to determine which pain management strategies improve patients' outcomes.