Improving Pain Management By Using the AE Campaign Frameworks - PowerPoint PPT Presentation

Loading...

PPT – Improving Pain Management By Using the AE Campaign Frameworks PowerPoint presentation | free to download - id: 5ceaf1-ZTNjN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Improving Pain Management By Using the AE Campaign Frameworks

Description:

Title: Implementing Pain Management Guidelines Author: Steven Levenson Last modified by: Jenny Harrison Created Date: 6/5/2000 12:03:50 AM Document presentation format – PowerPoint PPT presentation

Number of Views:62
Avg rating:3.0/5.0
Slides: 84
Provided by: Steven592
Learn more at: http://www.metastar.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Improving Pain Management By Using the AE Campaign Frameworks


1
Improving Pain Management By Using the AE
Campaign Frameworks
  • For Short- and Long-Stay Patients (Campaign Goals
    3 and 4)

2
Goal 3 Pain in Long-Stay Individuals
  • By September 2008
  • National average of moderate or severe pain
    experienced by long-stay residents will be at or
    below 4

3
Goal 3 Pain in Long-Stay Individuals
  • 30 of nursing homes will regularly report rates
    of moderate to severe pain for long-stay
    residents under 2
  • No nursing home will report a rate of moderate or
    severe pain that exceeds 20
  • Compared to June 2006, approximately 40,000 fewer
    long-stay residents will suffer from moderate or
    severe pain

4
Goal 4 Pain in Short-Stay Individuals
  • By September 2008
  • National average of moderate or severe pain
    experienced by post-acute residents will be at or
    below 15

5
Goal 4 Pain in Short-Stay Individuals
  • 30 of nursing homes will regularly report rates
    of moderate or severe pain for post-acute
    residents below 10
  • No nursing home will report a rate of moderate or
    severe pain that exceeds 46
  • Compared to June 2006, approximately 130,000
    fewer post-acute care residents will suffer from
    moderate or severe pain

6
This Webinar
  • Two Key Components
  • A- Overview of steps to improving systems and
    processes related to pain management
    (Implementation Framework)
  • B- Overview of key issues in assessing and
    managing pain (Pain Management Process Framework)

7
A Steps to Improve Systems and Processes Re
Pain Management
  • Performance improvement aspect
  • Pain Implementation Framework
  • Approach to Implementation
  • Applies Performance Improvement principles to
    clinical issues

8
Implementation Recognition / Assessment
  • 1. Identify pain management as an area for
    potential improvement in facility performance
  • Why is pain management an area for potential
    improvement in all settings?

9
Pain Management Challenges
  • Pain, like behavior, is one of the most
    challenging and complex of all symptoms
  • Often, many factors / causes coexist

10
Pain as a Complex Symptom
11
Pain Management Challenges
  • Identifying specific causes may be difficult
  • Symptoms
  • Often subtle, nonspecific
  • Can be misleading
  • For example, referred pain
  • Subjective and objective matches and mismatches

12
Pain Management Challenges
  • Interventions only sometimes effective
  • Effective approaches vary for different people
    with similar symptoms and causes

13
Pain Management Challenges
  • All analgesics have issues
  • Complications from mild to severe
  • Balance pain management with side effects
  • Apply information and recommendations on the
    subject to actual cases
  • Book knowledge vs. clinical skill

14
Pain Management Challenges
  • Need skilled application of good intentions
  • Challenge for even the best clinicians
  • Characterize the problem correctly
  • Identify the causes
  • Balance risks and benefits of interventions
  • Choose from among numerous treatment alternatives
    and combinations
  • Make interventions in proper context

15
Pain Management Challenges
  • With adequate knowledge, skills, and careful care
    process
  • Possible to do a reasonable job in managing pain,
    most of the time
  • Still a need for thoughtful reassessment and
    treatment adjustment

16
Pain Management Challenges
  • With inadequate knowledge, skills
  • Sometimes lucky guess
  • Often less than optimal results
  • Sometimes dangerous or deadly
  • Especially when improper treatment selection gt
    additional doses or medications gt more symptoms
    d/t complications gt more medications gt etc.
  • Failure to seek or recognize causes may allow
    progression of serious underlying illness

17
Implementation Recognition / Assessment
  • 2. Identify authoritative information available
    for the topic
  • What is authoritative?
  • Sources that tell how to assess and manage
    patient with pain, not just pain
  • Reflects how actual care should be delivered
  • Consistent with process framework
  • Emphasize problem definition / cause
    identification, not just assessment and treatment

18
Implementation Recognition / Assessment
  • What is authoritative?
  • Focus on process and decision-making points, not
    just forms, tools, and advice
  • Interventions in proper context, not just blanket
    recommendations
  • Offer balanced perspective on choosing
    interventions
  • Balance enthusiasm with caution
  • Examples
  • AMDA and AGS Pain Guidelines
  • Others

19
Implementation Recognition / Assessment
  • 3. Identify current processes and practices in
    the facility
  • Identify facilitys current approach to
    individuals with pain (What are we doing?)
  • Who in the facility decides how to address
    individuals with pain, and what approaches do
    they use? (Who decides?)

20
Implementation Recognition / Assessment
  • How do current approaches match up with the Pain
    Management Process Checklist and framework, and
    related authoritative information? (Right thing
    done in the right way?)
  • Compare current with desirable approaches to
    managing individuals with pain
  • Start Pain Management Process Checklist
  • Details Pain Process Framework

21
Implementation Recognition / Assessment
  • 4. Identify areas for improvement in processes
    and practices
  • Based on information obtained in Steps 2 and 3
    above, identify less than optimal practices and
    performance
  • Identify whether anyone has been reviewing and
    comparing current approaches to pain management
    to desirable ones (How do we know?)

22
Implementation Recognition / Assessment
  • Have issues been identified previously related to
    managing those with pain? Were they followed up
    on?
  • Has the facility previously evaluated its
    performance and taken measures to improve?

23
Implementation Cause Identification
  • 5. Identify the causes of issues related to
    preventing and managing pain, including root
    causes of undesirable variations in performance
    and practice
  • What is promoting or inhibiting desired
    management of individuals with pain
  • Reasons given by those who do not adequately
    follow desirable approaches (Why will or wont
    they do what we need them to do?)

24
Implementation Cause Identification
  • Examples
  • Dont know what to do, or how to do it right
  • Think their way is better
  • Think your way wont work
  • Positive consequences for wrong thing
  • Fear negative consequences
  • Fournies FF. Why Employees Dont Do What They Are
    Supposed to Do, and What to Do About It. New
    YorkMcGraw-Hill, 1999.

25
Implementation Management
  • 6. Reinforce optimal practice and performance
  • Continually promote doing the right thing in the
    right way
  • Follow steps in the Pain Management Process
    Framework, throughout the facility
  • Details from authoritative sources

26
Implementation Management
  • Based on information and data collected about the
    organization and the processes and results
    related to pain management
  • Reinforce systems and processes that are already
    optimal
  • Also correct or inhibit other variations
  • Right thing / wrong way wrong thing / right way
    wrong thing / wrong way

27
Implementation Management
  • Identify and use tools and resources to help
    implement the steps and address related issues
  • Clinical tools to care for residents and patients
  • Management tools to strengthen care systems and
    processes

28
Implementation Management
  • 7. Implement necessary changes
  • Implement pertinent generic and cause-specific
    interventions
  • Address underlying causes (including root causes)
    of the challenges and obstacles to the facilitys
    capacity to manage pain effectively and safely

29
Implementation Management
  • Address issues of individual performance and
    practice that could be improved in trying to
    improve pain management
  • Establish and/or strengthen systems
  • Systematic approach and key principles transcend
    individuals

30
Implementation Monitoring
  • 8. Reevaluate performance, practices, and results
  • Recheck for progress towards getting the right
    thing done consistently in the right way
  • Reuse Pain Management Process Checklist to
    identify whether all key steps are being followed

31
Implementation Monitoring
  • Use Pain Management Process Framework and related
    references and resources, and repeat Steps 2-7
    (Recognition / Assessment, Cause Identification,
    and Management) until processes and practices are
    optimal
  • Continue to collect data on results and processes

32
Implementation Monitoring
  • Evaluate whether changes in process and practice
    have helped attain desired results
  • Adjust approaches as necessary

33
B- Key Aspects of Managing Individuals With Pain
  • Pain Process Framework Highlights
  • Recognition / Assessment
  • Cause Identification / Diagnosis
  • Management / Treatment
  • Monitoring
  • Care process coincides with Performance
    Improvement approaches
  • General framework for effective problem solving

34
Challenges Brief Review
  • Complex symptom often requiring detailed
    understanding of the patient and thoughtful
    interpretation of symptoms
  • Following steps and taking correct actions at
    those steps
  • Not easy to manage effectively without doing harm
    while trying to do good

35
RECOGNITION / ASSESSMENT Goals
  • Recognize individuals with pain
  • Define symptoms in detail and in context
  • Identify individuals requiring close scrutiny

36
Step 1 Surveillance
  • Look for pain and those at risk for pain
  • Have a systematic approach to trying to identify
    individuals with pain or pain risk
  • Same as with many other issues, symptoms
  • Ask about it

37
Step 1 Surveillance
  • Initiate assessment within 24 hours of arrival or
    condition change
  • Periodically ask and observe residents / patients
    about pain
  • Approaches depending on the situation

38
Step 1 Surveillance
  • Asking or looking is just a screen - additional
    important details needed
  • Facility provides specific guidance
  • For example, via protocols, guidelines, or
    policies and procedures
  • For staff, practitioners, residents, families

39
Step 2 Risk Factors
  • Identify significance of risk factors that could
    relate to pain or the risk of having pain

40
Step 2 Risk Factors
  • Many predisposing diseases and conditions
  • Often related to reason for recent
    hospitalization
  • But may also be coincidental
  • Example Hip fracture, surgical site infection,
    arthritis

41
Step 3 Details
  • Identify and document characteristics of pain
  • Challenges of detection and symptom reporting

42
Details Count!
43
Step 3 Details
  • Details needed for proper interpretation of any
    symptom
  • Details always important, but especially critical
    when
  • Partial or limited improvement with treatment
  • Complicated or recurrent pain
  • Multiple or higher risk analgesics used

44
Step 3 Details
  • Details especially critical when
  • Treatments need frequent adjustment
  • More medications added or doses of existing
    medications increased
  • Multiple or unclear causes
  • Trying to distinguish nonspecific symptoms that
    could represent pain from other causes with
    similar symptoms
  • Restlessness, grimacing, insomnia, etc

45
Step 3 Details
  • Details especially critical when
  • Efficacy of interventions questionable
  • Patient possibly suffering complications from
    interventions
  • Subsequent actions depend on details about
    current symptoms in context of previous symptoms
    (degree of relief, frequency, compared to
    recently and related to previous doses and
    frequency of administration)

46
Step 3 Details
  • Not enough just to say Still complains of pain,
    Not getting relief, Asked for more
    medication, etc
  • Consider what is really reported to, and
    discussed with, practitioners
  • Often amazingly superficial

47
Step 3 Describe and Document
  • Identify and document characteristics of pain
  • Challenges of symptom documentation
  • Chart documentation about pain typically sparse
  • Use of pain forms and tools OK
  • But they are not always needed or only portions
    needed
  • How much to document, and when

48
Step 3 Describe and Document
  • Interpretation of information critical, helped by
  • Chronology (the story)
  • Essential deserves extra effort
  • Other symptom details
  • Objective observations and comparisons

49
Step 3 Describe and Document
  • Interpretation of Information
  • Identify type and causes of pain
  • Differentiate pain from other conditions that
    cause nonspecific symptoms
  • Caution in assuming to be due to pain unless
    verified and/or other possible conditions
    considered
  • Effectiveness of interventions

50
Step 3 Describe and Document
  • Pain scales
  • Useful for intensity, but need to be combined
    with information about other elements of pain
  • As with other rating scales, much more useful
    when comparative, and related to frequency, type
    and timing of interventions, including doses of
    medications

51
Step 4 Inform and Discuss
  • Notify and discuss with a practitioner symptoms
    that may represent pain
  • Practitioner evaluation
  • Clarifying the problem statement
  • Identifying causes
  • Including direct patient examination, as needed

52
Step 4 Inform and Discuss
  • Not necessary every time, but strategically
  • Strategic notification
  • When pain symptoms identified initially, after
    collecting appropriate information
  • When causes not clear
  • When important additional information available

53
Step 4 Inform and Discuss
  • Strategic notification
  • When current interventions do not appear to be
    adequate
  • When patient still has pain despite adding
    interventions and increasing medication doses,
    after a reasonable amount of time
  • When secondary or additional causes arise

54
Step 5 Seek Causes
  • Seek to identify or clarify specific causes of
    pain
  • Important to pursue underlying cause(s)
    vigorously
  • Based on information gathered through various
    sources including interview, record review, and
    examination
  • Many pain management options not cause-specific

55
Step 5 Seek Causes
  • Perform additional investigation for causes, as
    warranted
  • Practitioner takes relevant medical history and
    examines individual
  • Especially for severe or persistent pain, or not
    responding readily to treatment
  • Pain often has specific, identifiable causes,
    although not always possible to find or correct
    underlying cause

56
Step 5 Seek Causes
  • Addressing underlying causes may relieve pain or
    reduce its frequency and intensity
  • When causes cannot be resolved, try to stabilize
    or reduce impact while treating resulting pain

57
Step 6 Identify Goals
  • Identify pain management goals
  • Staff, practitioner, resident, and family
    collaborate
  • For example, relief of pain, reduction of pain to
    a tolerable level, reduce need for breakthrough
    pain medication, etc
  • Goal needed to help identify whether
    interventions are relevant and effective

58
Step 6 Identify Goals
  • Goals may need to be adjusted over time
  • Depending on causes, prognosis, effectiveness of
    initial interventions, and other factors
  • Total pain relief desirable but not always
    possible
  • May be tradeoffs between pain control and
    undesirable treatment effects

59
Step 7 Manage Pain and Its Underlying Causes
  • Staff and practitioner review
  • Causes and characteristics of an individuals
    pain
  • Options (including non-pharmacologic measures)
    for managing pain
  • Implement plan to manage pain and related
    treatable causes

60
Step 7 Manage Pain and Its Underlying Causes
  • Use recognized options for pain management
  • As identified in pertinent protocols and
    guidelines
  • Or, provide a clinically valid reason for other
    approaches

61
Step 7 Manage Pain and Its Underlying Causes
  • Various non-pharmacologic options may help
  • Depending on cause and location of pain,
    residents response to interventions, causes,
    other factors

62
Step 7 Manage Pain and Its Underlying Causes
  • Analgesics (pain medications) often very
    effective
  • When used properly
  • Not always needed
  • Effectiveness varies widely
  • Can cause significant complicationsalone or
    (often) in combination

63
Medications Guiding Principles
  • Reassess and adjust dose as often as needed
  • Evaluate situation, including nature and severity
    of symptoms and causes
  • WHO Pain ladder
  • A general guide
  • Use requires careful individualized assessment
  • Some medications in list inadvisable

64
Medications Guiding Principles
  • PRN medications may work for intermittent pain,
    or to help establish a dose and frequency target
    for longer-acting medications, or depending on
    symptoms and patient goals

65
Medications Guiding Principles
  • Consider standing medication dose if
  • Frequent PRN use
  • Increasing doses and shorter intervals of
    medications
  • Pain severe and unrelenting
  • Uncorrectable underlying cause(s) that can be
    expected to cause pain at high level

66
Medications Guiding Principles
  • Chronic or lesser level acute pain
  • Start with low dose and systematically increase
    until highest tolerable dose reached
  • More severe acute pain
  • Start with moderate or higher dose and then
    adjust up or down as needed

67
Pain Medications A Few Thoughts
  • Pain is complex, involving many organ systems and
    several pathways
  • Medications are often very helpful
  • Medications have limited sites and mechanisms of
    action
  • All analgesics and adjuvants have risks, from
    minor to severe

68
Pain Medications A Few Thoughts
  • Often, complications result from combinations,
    for example
  • NSAIDs ASA or bisphosphonates
  • Opioids multiple psychopharmacologic
    medications cardiovascular medications
  • Reducing doses, changing medications, or reducing
    or eliminating other medications may minimize
    these adverse effects

69
Pain Medications A Few Thoughts
  • Refer to F329 guidance for key issues related to
    medications, including analgesics
  • Proper selection and extended use requires
  • Substantial clinical judgment and skill
  • Careful assessment and interpretation of
    information

70
Pain Medications A Few Thoughts
  • Pain relief should improve as dose and frequency
    of dosing increase
  • If not, the medication may not be right for the
    situation
  • Attempted tapering of doses or switching of
    medications is often indicated
  • When cause resolves or better controlled,
    symptoms stabilize, significant side effects
    occur
  • Hard to know unless we try
  • Can help lower overall medication risks

71
Pain Medications A Few Thoughts
  • Nonpharmacologic measures often work well, alone
    or in combination with medications
  • May take more time, and thus be underused
  • Only a few complementary therapies shown more
    beneficial than placebos

72
Analgesics Acetaminophen
  • Often good first choice or as a baseline in
    combination with something else in those without
    significant liver disease
  • Generalized discomfort, nonspecific symptoms,
    musculoskeletal conditions including
    osteoarthritis

73
Analgesics Acetaminophen
  • Example 500 or 650 mg. q4h 8AM-8PM and q4h PRN
    8PM-8AM
  • Monitor liver function periodically for long-term
    use, especially doses 2-4 gm/day

74
Analgesics NSAIDs
  • Nonsteroidal anti-inflammatory agents
  • Musculoskeletal conditions, generalized or
    nonspecific symptoms, inflammation
  • Beyond a point, increasing dose offers little
    additional pain relief and may produce added side
    effects
  • Monitor significant gastrointestinal,
    cardiovascular, renal risks

75
Opioids
  • Mechanism of action
  • Primarily, inhibit neurotransmitter release and
    response, pre- and post-synaptic
  • Helpful in many circumstances, but not helpful or
    problematic in many others
  • Example fibromyalgia
  • Potential to cause delirium and/or impair
    function and cognition with chronic use in frail,
    elderly individuals

76
Opioids
  • Adverse consequences can be painful
  • Urinary retention, intestinal ileus, nausea and
    vomiting, etc
  • Use judiciously
  • Good intentions misuse may gt preventable
    complications
  • Extended use should be based on careful review
  • Especially for enduring non-cancer pain

77
Steps 8-10 Reassess and Adjust
  • Periodically reassess the status of an
    individuals pain
  • Ongoing evaluation essential
  • Staff and practitioner reassess individuals with
    pain and those at risk for pain
  • Identify degree of comfort, status of underlying
    causes, effectiveness of interventions

78
Step 8-10 Reassess and Adjust
  • Periodically reassesses individuals who are
    receiving long-term analgesics
  • Periodically reconsider doses and ongoing use
  • Pain can subside, and causes of pain sometimes
    resolve or become less intense
  • Analgesics and other interventions can sometimes
    be tapered, stopped, or changed to lower risk
    approaches

79
Step 8-10 Reassess and Adjust
  • If pain does not respond adequately to selected
    interventions, reconsider current approaches
  • Careful assessment including practitioner review
    and evaluation before repeatedly adding more
    medications or doses

80
Step 8-10 Reassess and Adjust
  • Monitor for significant effects, side effects,
    and complications of pain medications
  • Essential to distinguish symptoms due to
    complications of existing treatments from those
    due to existing or new medical conditions

81
Step 8-10 Reassess and Adjust
  • Complications of treatments can themselves be
    painful
  • Must be aware of potential complications and take
    them seriously
  • If valid clinical reason to continue medication
    despite complication, close monitoring needed

82
Challenges
  • When patient still having pain symptoms despite
    multiple interventions
  • When increasing medication doses do not seem to
    bring relative relief
  • When health care practitioner is not readily
    available or not helpful
  • When it is unclear whether a patients symptoms
    truly represent pain

83
Performance and Facility Management
  • Efforts to improve and sustain care present
    specific clinical and management challenges
  • Preventive management interventions after initial
    implementation
  • Cannot just wind it up and let it run
  • Coordinated action from both facility management
    and clinical supervisors
  • Pain management as a barometer of facilitys
    clinical systems / processes
About PowerShow.com