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Improving Pain Management By Using the AE Campaign Frameworks


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

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Title: Improving Pain Management By Using the AE Campaign Frameworks

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

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

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

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

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

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)

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

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?

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

Pain as a Complex Symptom
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

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

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

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

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

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

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

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
  • Offer balanced perspective on choosing
  • Balance enthusiasm with caution
  • Examples
  • AMDA and AGS Pain Guidelines
  • Others

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?)

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

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
  • Identify whether anyone has been reviewing and
    comparing current approaches to pain management
    to desirable ones (How do we know?)

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

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?)

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.

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

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
  • Also correct or inhibit other variations
  • Right thing / wrong way wrong thing / right way
    wrong thing / wrong way

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

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

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

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

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
  • Continue to collect data on results and processes

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

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

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

  • Recognize individuals with pain
  • Define symptoms in detail and in context
  • Identify individuals requiring close scrutiny

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

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

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

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

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

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

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

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

Step 3 Details
  • Details especially critical when
  • Efficacy of interventions questionable
  • Patient possibly suffering complications from
  • 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)

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

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
  • How much to document, and when

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

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
  • Effectiveness of interventions

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

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

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

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

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

Step 5 Seek Causes
  • Perform additional investigation for causes, as
  • 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

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

Step 6 Identify Goals
  • Identify pain management goals
  • Staff, practitioner, resident, and family
  • 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

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
  • May be tradeoffs between pain control and
    undesirable treatment effects

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

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

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

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

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

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

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

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

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
  • All analgesics and adjuvants have risks, from
    minor to severe

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

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

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
  • Attempted tapering of doses or switching of
    medications is often indicated
  • When cause resolves or better controlled,
    symptoms stabilize, significant side effects
  • Hard to know unless we try
  • Can help lower overall medication risks

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

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

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

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
  • Monitor significant gastrointestinal,
    cardiovascular, renal risks

  • 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

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

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

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

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

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

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

  • 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

Performance and Facility Management
  • Efforts to improve and sustain care present
    specific clinical and management challenges
  • Preventive management interventions after initial
  • 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