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Quality Improvement Initiative to Improve Postoperative Pain with a Clinical Pathway and Nursing Education Program
Original Article Quality Improvement Initiative to Improve Postoperative Pain with a Clinical Pathway and Nursing Education Program Dahlia Naqib, MD, Mike Purvin, MD, Rashmi Prasad, MD, Irini M. Hanna, BS, Sandra Dimitri, MBChB, Angela Llufrio, RN, MSN, CRNP, and Marie N. Hanna, MD, MEHP ---
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From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland. Address correspondence to Marie N. Hanna, MD, MEHP, Associate Professor, Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, 1800 Orleans Street, Zayed 8120, Baltimore, MD 21287. E-mail: [email protected] Received December 15, 2017; Revised June 4, 2018; Accepted June 26, 2018. 1524-9042/$36.00 Ó 2018 by the American Society for Pain Management Nursing https://doi.org/10.1016/ j.pmn.2018.06.005
ABSTRACT:
Background and Aims: We created a multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery. Design: A multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery. Settings: Pain management education of postanesthesia recovery room nurses through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance. Participants/Subjects: Postanesthesia recovery nurses/ postanesthesia patients. Methods: The intervention included two components: a clinical pain pathway on multimodal analgesia for both opioid-na€ıve and opioid-tolerant patients undergoing surgery and an educational program on pain management for frontline clinical nurses in the postanesthesia care unit (PACU). We measured the intervention’s impact on time to pain relief, PACU length of stay, and patient satisfaction with pain management, as measured by self-report. Results: Patient PACU surveys indicated a decrease in the percent of patients with opioid tolerance who required more than 60 minutes to achieve adequate pain relief (from 32.7% preintervention to 21.3% postintervention). Additionally, after the intervention, the average time from a patient’s PACU arrival to his or her discharge criteria being met decreased by 53 minutes and PACU stay prolongation as a result of uncontrolled pain for opioidtolerant patients decreased from 45.2% to 25.7%. The sample size was underpowered to perform statistical analysis of this Pain Management Nursing, Vol -, No - (--), 2018: pp 1-9
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improvement. Conclusions: After the combined intervention of a clinical pain pathway and interactive teaching workshop, we noted shortened PACU length of stay, reduced time to reach pain control, and improved overall patient satisfaction. Although we could not determine statistical significance, our findings suggest improved management of acute postoperative pain, especially for patients who are opioid tolerant. Because of the paucity of data, we were not able to conduct the analysis needed to evaluate quality improvement projects, as per SQUIRE 2.0. could be adopted by any institution. Ó 2018 by the American Society for Pain Management Nursing Pain management is increasingly recognized as an important aspect of high-quality care and an integral component of patient satisfaction (Baker, van der Meulen, Lewsey, & Gregg, 2007; Fung, Cohen, Stewart, & Davies, 2005). Based on the Agency for Health Care Policy and Research guidelines for acute pain management, appropriate pain management for postoperative patients contributes to earlier mobilization, shortened hospital stay, and reduced costs (The Agency for Health Care Policy and Research, 1992). Additionally, undertreatment of postoperative pain and the consequent decline in patient satisfaction can have negative effects on the economics of a health system (Koo, 2007). Pain management is a central focus of Enhanced Recovery After Anesthesia Pathways (Tan, Law, & Gan, 2015). In view of the undertreatment of postoperative pain, the American Society of Anesthesiologists established the Task Force on Acute Pain Management and published guidelines promoting standardization of procedures. The pain task force also recommended the use of patient-controlled analgesia and multimodal analgesia (American Society of Anesthesiologists Task Force on Acute Pain Management, 2012). Despite these efforts, results from clinical studies suggest that postoperative pain continues to be undertreated (Apfelbaum, Chen, Mehta, & Gan, 2003; Benhamou et al., 2008). Clinical barriers identified in this aspect of postoperative care need to be addressed because patients’ reports of satisfaction are increasingly used in public reporting, in pay-for-performance programs, and by the news media. Also, multiple studies have reported positive relationships between patients’ experiences and the quality of clinical care in U.S. hospitals (Elliott et al., 2010; Hanna et al., 2012; Jha, Orav, Zheng, & Epstein, 2008).
Previous studies have found that implementation of quality improvement strategies in hospitals has a beneficial effect on patient outcomes (Castle, Brown, Hepner, & Hays, 2005; Sunol et al., 2009). Institutional pain management programs that approach pain from a multidimensional perspective need to be developed and their impact on outcomes evaluated. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a standardized instrument and data collection methodology used to measure and publicly report patients’ experiences of hospital care (Elliott et al., 2010). The HCAHPS survey is mandated by the Centers for Medicare and Medicaid, which also oversees administration of the survey. The 2008 HCAHPS survey, which covers seven domains of care, contains 27 questions related to satisfaction with care and respondent demographic information. One of the seven domains addresses pain management with the following two questions: ‘‘During this hospital stay, how often was your pain well-controlled?’’ and ‘‘During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?’’ (Elliott et al., 2010). Studies have found a positive correlation between HCAHPS survey responses and the quality of clinical care in U.S. hospitals (Elliott et al., 2010; Hanna et al., 2012; Jha et al., 2008). Our hospital consistently ranks high in most subspecialties of medicine and surgery, but the HCAHPS survey data illustrate that it needs much improvement in the area of pain management. Previous studies have reported the importance of pain experts, such as those on an acute pain service, and that the lack of staff with expertise in pain management is a predictor of poor compliance with pain guidelines (Jiang et al., 2001; Mackintosh & Bowles, 2000). Although significant emphasis has been placed on good pain control and patient satisfaction, there is also growing recognition of the adverse effects of opioids (Center for Behavioral Health Statistics and Quality, 2015; Centers for Disease Control and Prevention, 2017; Ostling et al., 2018). The use of opioids for the treatment of chronic noncancerous chronic pain is highly controversial (Gupta & Atcheson, 2013). With increased understanding of how prescribers are contributing to the opioid epidemic, providers are turning to opioid-sparing multimodal pain control (Buvanendran & Kroin, 2009; Elvir-Lazo & White, 2010; Gauger, Gauger, Desai, & Lee, 2018). Opioids still have a place in postoperative pain control, but the opioid-sparing properties of a multimodal approach are considered preferable (Barth, Guille, McCauley, & Brady, 2017). There are many missed opportunities to use multimodal analgesia at our institution.
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INTERVENTIONS We sought to identify areas in which we could improve perioperative pain control by using our institution’s established framework of the Comprehensive Unit-Based Safety Program (CUSP). CUSP has been implemented in many units at our hospital to improve the local culture of safety, teamwork, and communication. The focus of a CUSP team is to identify and mitigate hazards in a unit. As an example, local implementation of interventions through CUSP, coupled with evidence-based central-line insertion and maintenance practices, has worked well to reduce bloodstream infections (Watson et al., 2009). We collaborated with the CUSP team to identify local barriers and implement solutions for improved pain control within our postanesthesia care unit (PACU). Using the 2009 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) selfassessment questionnaire (The Joint Commission, 2009), we asked the PACU nurses to assess how well their respective unit addresses the issue of pain control and educates unit providers on how to evaluate and treat patients’ pain. Only 29% of respondents thought that staff in their unit always receive education or training about pain assessment and management, and only 27% thought that staff has access to guidelines for pain management in their surgical units. Our initial surveys helped to identify some local barriers to improving pain management in the PACU—namely, lack of nursing education in postoperative pain control and managing pain in patients who are opioid tolerant. We received approval from the institutional review board for the collection of deidentified data using the PACU Pain Outcome Measurement Tool (Appendix D). Patient consent was not required. We implemented our intervention in a PACU that serves 17 operating rooms and sees a mixture of adult inpatient and outpatient surgical patients, including orthopedic, otolaryngology, colorectal, urology, gynecology, surgical oncology, plastics, and endocrinology cases. It is a diverse mixture of patients and cases. These are mostly extensive surgeries requiring postoperative admission or routine outpatient surgeries on patients with significant morbidity. These operating rooms perform few outpatient procedures in healthy patients because these procedures are usually performed in a separate outpatient center. The intervention included two components: (1) the creation and distribution of a Clinical Pathway for Pain Management (CPPM) with multimodal recommendations for patients undergoing surgery (Appendix A) and (2) an educational pain management workshop for perioperative nurses.
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THE CLINICAL PATHWAY FOR PAIN MANAGEMENT Based on current knowledge of multimodal pain control methods (Appendix C), the acute pain team created the CPPM for multimodal analgesia in patients undergoing surgery. The CPPM provides separate recommendations on appropriate pain interventions for opioid-na€ıve and opioid-tolerant patients. The pathway was peer reviewed by several disciplines, including anesthesia, surgery, nursing, and pharmacy. After the team reached a consensus, a one-page visual aid was created (Appendix A). Multiple copies were printed and laminated, handed out to the nurses, and taped onto the wall of the nurses’ station in one 28-bed PACU. The CPPM was also presented to the anesthesiology department during grand rounds, and copies were given to all anesthesia providers. Our rationale was that by using this clinical pathway, providers would have a guideline when placing multimodal analgesic orders, with the understanding that nurses would execute those orders based on clinical judgment. Our PACU nurses used the CPPM to remind and encourage the prescribing providers to place the multimodal medication orders. Prescribing providers place orders according to their own clinical judgment. If the surgeon did not want to prescribe nonsteroidal antiinflammatory drugs (NSAIDs), for example, they were omitted. The CPPM was not mandated; it served instead as a reminder tool and ordering guideline.
PAIN MANAGEMENT WORKSHOP We educated all 37 of the PACU nurses in the chosen area using a teaching workshop that was scheduled around their clinical shifts. In our institution, pain management education was very limited, and access to a pain management education tool was not common (Gonzalez-Fernandez et al., 2014). We decided to move away from traditional classroom lectures and introduce interactive teaching through cases. Three case scenarios were prepared and revised by a group of pain faculty. One pain faculty member, one fellow, and two residents recorded videos in patient rooms. Cases reinforced the learning of multimodal analgesia and its benefit in pain management. We presented the cases in a format of problem-based learning (Rosenblatt, 2004) to PACU nurses. The nurses were first provided with the rationale for treatment of postoperative pain. Instructors presented a review of the morbidity associated with inadequate pain control and the corresponding literature citations. Next, nurses were introduced to the benefits of multimodal analgesia and taught the mechanism of
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action, indications, and contraindications of acetaminophen, gabapentin, pregabalin, NSAIDs, celecoxib, opioids (particularly methadone), and ketamine. Finally, the instructor showed the three videos and asked questions (Appendix B); nurses were given the opportunity to answer the questions and receive correct explanations in a group discussion that was guided by slides. Case 1 introduced the effective use of epidural analgesia as part of multimodal therapy, case 2 introduced the importance of using peripheral nerve catheters in orthopedic patients, and case 3 presented pain treatment options in opioid-tolerant patients (Appendix B). Nurses attended the workshops voluntarily, were scheduled for either before or after their clinical shifts, and were given 10 minutes at the end of every workshop to ask questions. Three to five nurses were present at each of the six workshops that we held. Two months after the workshop, all 37 PACU nurses were asked to complete the Knowledge and Attitudes Survey Regarding Pain Management that we had revised for use as an evaluation tool to assess health care professionals’ knowledge of pain management (Ferrell & McCaffery, 2014). We also asked the PACU nurses to assess how well their respective unit addressed the issue of pain control and educated staff on how to evaluate and treat patients’ pain. We used the 2009 JCAHO self-assessment questionnaire (The Joint Commission, 2009). We also asked the nurses to evaluate the pain workshop and to provide feedback.
EVALUATION OF INTERVENTION SUCCESS To evaluate the effect of the interventions on postoperative pain control, we conducted patient-centered assessments of pain management in the PACU using a combined nurse-patient survey (Appendix D). Patients
responded to questions regarding their perception of pain control while they were in the PACU. Surveys were conducted by the PACU nurses for 6 months before implementation of the interventions and then for another 6 months beginning 2 months after the interventions were complete. The survey consisted of two parts. Questions in Part 1 related to pain management in the recovery room and were answered by the nurse caring for the patient (questions 1-14, Appendix D). Information gathered in this part included (1) the length of time for the patient to experience pain relief after arrival to the PACU and (2) the duration of time from PACU admission to the discharge criteria being met. In Part 2, a nurse not participating in the patient’s care asked the patient to respond to questions regarding his or her perception of pain control (Appendix D, Part 2). These questions were asked immediately before discharge from the PACU. Two of these questions were very similar to the pain-related questions in the HCAHPS survey (Elliott et al., 2010): ‘ How often was your pain well controlled?’’ and ‘ How often did staff do everything they could to help with pain control?’’ Before the intervention, we collected 399 PACU patient-centered surveys. The results indicated that 82 patients (20.5%) had a history of opioid tolerance, defined as use of opioids for at least 2 weeks before surgery (question 1 in Appendix D). Patients with a history of opioid tolerance differed from opioid-na€ıve patients on a number of metrics (Table 1). More than half of opioid-tolerant patients (51.3%) reported a PACU admission pain level of $7 out of 10 compared with 28.5% among other patients. In addition, 32.7% of opioid-tolerant patients required more than 60 minutes until pain relief, whereas only 11.2% of opioidna€ıve patients required that much time. The PACU length of stay was longer for opioid-tolerant patients (3 hours and 37 minutes) than for opioid-na€ıve patients (3 hours and 9 minutes). Furthermore, 45.2% of opioidtolerant patients had their PACU stay prolonged
TABLE 1. Preintervention Survey of Patient Experience with Pain Control in Postanesthesia Care Unit Stratified by History of Opioid Tolerance History of Opioid Tolerance Parameter Pain score on arrival to PACU was 7/10 or greater Pain was always well controlled Required more than 60 min for pain relief after PACU arrival Time from PACU arrival to meeting of discharge criteria PACU stay was prolonged because of uncontrolled pain PACU ¼ postanesthesia care unit.
No (n ¼ 317) 28.5% 69.5% 11.2% 3 h:9 min 15.7%
Yes (n ¼ 82) 51.3% 55.6% 32.7% 3 h:37 min 45.2%
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TABLE 2. Survey of Opioid-Tolerant Patients’ Experience with Pain Control in Postanesthesia Care Unit Before and After Intervention Parameter
Before Intervention (n ¼ 82)
After Intervention (n ¼ 87)
Reported that pain was always well controlled in PACU Required more than 30 min for pain relief after PACU arrival Required more than 60 min for pain relief after PACU arrival PACU stay was prolonged because of uncontrolled pain Time from PACU arrival to meeting of discharge criteria
55.6% 54.5% 32.7% 45.2% 3 h, 37 min
68.7% 43% 21.3 % 25.7% 2 h, 44 min
PACU ¼ postanesthesia care unit.
because of uncontrolled pain, compared with 15.7% of other patients. Unfortunately, we received only 102 postintervention surveys. This number was inadequate to power statistical analysis of the impact of our interventions. Of the 102 postintervention surveys, 87 were for patients with opioid tolerance. Although we were unable to determine statistical significance, we did identify trends in the data. Because the majority of postintervention surveys were from opioid-tolerant patients, we chose to look at trends in this group only. When we compared data from opioid-tolerant patients before and after the interventions, we found that the percentage of patients who reported that pain was always controlled increased from 55.6% before the intervention to 68.7% after the intervention. Additionally, we found a decrease in the
percentage of patients who required more than 60 minutes for pain relief in the PACU (from 32.7% to 21.3%) and a 53-minute decrease in the average time from a patient’s PACU arrival to his or her discharge criteria being met (from 3 hours, 37 minutes to 2 hours, 44 minutes; Table 2). Two months after the workshop, 34 out of 37 PACU nurses (91%) completed the knowledge questionnaires and JCAHO survey in pain management. Knowledge questionnaire scores improved to an average of 69%, compared with 49% in our study conducted 2 years earlier (Gonzalez-Fernandez et al., 2014). The JCAHO self-assessment results (Table 3) indicated that more than 90% of PACU nurses selfassessed their working unit to have a standard protocol and guidelines for pain management practice. More than 80% believed that their staff are regularly
TABLE 3. Summary of Nurse Responses to the JCAHO Self-Assessment Questionnaire Self-Assessment Questions Does your surgical unit document ongoing pain assessment and interventions? Does your surgical unit have a written pain protocol or standard of practice? Does your surgical unit’s method for pain documentation place pain intensity in a highly visible or prominent position that encourages regular view by all staff? Does your organization have standards or guidelines that define the maximum acceptable pain? Does your surgical unit’s staff have access to guidelines for pain assessment and management? Is staff regularly educated or trained about pain assessment and management? Does your organization maintain a supply of patient education materials for pain management? Are all patients educated about pain and the importance of effective management? Is pain included in the discharge planning process? Does your surgical unit ensure the communication of pain management when a patient transitions across health care settings? Have surgical unit leaders made pain a performance improvement priority? Is the assessment and management of pain integrated into competency and performance evaluations for staff and licensed independent practitioners? JCAHO ¼ The Joint Commission on Accreditation of Healthcare Organizations. *All data are shown as n (%).
Response of Always or Mostly Done (n ¼ 34)* 34 (100) 33 (97) 30 (88) 30 (88) 34 (100) 28 (82) 28 (82) 30 (88) 32 (94) 28 (82) 29 (85) 25 (74)
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educated and trained about pain assessment and management, that all patients are educated about pain and the importance of effective management, and that their unit leaders made pain a performance improvement priority (Table 3). More than 90% of the nurses evaluated the workshop as being extremely helpful and said that it made them comfortable managing pain in the PACU. More than 50% of respondents believed that repeating similar workshops would be helpful. Although the changes after the intervention seem favorable, we did not gather enough postintervention data to perform statistical analysis and therefore cannot conclude that the intervention was associated with a statistically significant improvement.
DISCUSSION The CPPM was created by a consensus of clinicians at our institution after careful literature review and has not been tested for effect on patient outcomes. The combined intervention of the CPPM and interactive teaching workshop appeared to have a favorable effect on the institution’s management of acute postoperative pain, especially for patients who were opioid tolerant. The preintervention survey results indicated that opioid-tolerant patients spent more time in the PACU and were less satisfied with their pain control than opioid-na€ıve patients. After the intervention, self-reports of pain control improved, fewer patients required more than 60 minutes for pain relief in the PACU, and PACU stays were shorter, although we cannot say if these changes are statistically significant. Two months after the workshops, we noted improvements in nurses’ knowledge of pain control and perception of unit standards on pain education and resources. Knowledge questionnaire scores improved to an average of 69% (from 49%). Nurse perceptions of the institution’s pain management guidelines, pain education practices, and commitment to the treatment of pain also increased from 29% in the previous study (Gonzalez-Fernandez et al., 2014) to 90% after the intervention. Although PACU nurses do not write any orders, they are important decision makers for patient pain control. They are the first line of patient care in the immediate recovery period after surgery, and they have the potential to be strong patient advocates. When we began our intervention, the concept of multimodal analgesia was new to the PACU nurses and ordering providers. The CPPM served as a reminder and educational tool regarding multimodal options, dosing, indications, and contraindications. The CPPM was not a required part of an order set, but we believe that
having the CPPM in hand did empower our PACU nurses to request these on patients’ behalf when they thought appropriate. A provider’s effort to pursue all possible multimodal agents to control a patient’s pain can strongly influence that patient’s perception of pain control. We previously examined the relationship between a patient’s perceptions of pain control and overall satisfaction with care (Hanna et al., 2012). Our results indicated that a patient’s perceptions of pain control and of staff’s efforts to control pain are associated with overall satisfaction scores. We also found that patients were more likely to rate their overall hospital experience highly if they perceived that their health care providers were doing everything they could to help control the pain and that their pain was well controlled. Interestingly, after we adjusted for age, sex, nurses’ courtesy, and physicians’ courtesy (communication), staff performance in managing pain was a stronger predictor of satisfaction than pain control itself. The odds of a patient being satisfied were 4.86 times greater if pain was always controlled as opposed to not always controlled and 9.92 times greater if staff performance was always appropriate with their care as opposed to not always appropriate with their care (Sunol et al., 2009). Hence, educating nurses about best treatment practices for pain control can substantially improve patients’ perceptions of the postoperative period. Nurses who took the knowledge and selfassessment questionnaires had positive comments regarding the effect of the workshop on their daily practice. Samples of these comments include the following: ‘‘We should have more teaching in pain management cases’’; ‘‘This learning made me more comfortable with the use of multimodal drugs in pain management’’; ‘‘I am not reaching out for narcotics like I used to for my patients’’; and ‘‘I feel all surgical residents need to attend these workshops.’’ The practice of perioperative pain management has changed significantly in the last two decades with the use of regional anesthesia, multimodal analgesia, and acute pain teams. However, acute pain management is extremely challenging in opioid-tolerant patients, especially in those with drug-seeking behavior (Aronoff, 2000; Carroll, Angst, & Clark, 2004; Chou et al., 2015). A comprehensive multimodal analgesic plan that includes regional analgesia may decrease opioid requirements in these patients (Minkowitz, Gruschkus, Shah, & Raju, 2014; Ong, Seymour, Lirk, & Merry, 2010). The use of nonopioid analgesics, including acetaminophen and NSAIDs, can help to decrease pain from inflammation and reduce subsequent opioid use (Elia, Lysakowski,
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& Tramer, 2005). Ketorolac is particularly useful because it has been found to decrease morphine use and morphine-related side effects (Cepeda et al., 2005). NMDA (N-methyl-D-aspartate) receptor antagonists such as ketamine potentiate the analgesic effects of opioids and may decrease opioid tolerance (Loftus et al., 2010). In randomized controlled studies, intraoperative administration of intravenous ketamine decreased opioid requirements after surgery (Loftus et al., 2010). In this project, we noted a favorable trend in nurse education and the pain control of opioidtolerant patients in the PACU. We did not have any data to suggest that teaching the workshop alone, without the CPPM, had an impact on nurses’ knowledge or on patient care. Nurses are vital members of our team, and, as such, their knowledge of the physiology and literature behind the modern-day approach to pain management is crucial. Nurses spend more time with patients than physicians do and are relied on to manage patients with significant postoperative pain. Our past surveys (Gonzalez-Fernandez et al., 2014) indicated that perioperative nurses had scant knowledge about pain management, pain medications, and the research supporting the use of epidural catheters and peripheral nerve blocks as part of multimodal analgesia. In our institution we laminated the CPPM and distributed it among our preoperative and PACU staff. The nursing staff has embraced the pathway. We have anecdotal reports that the nurses used the CPPM to remind residents to put in orders for multimodal medications. Such actions highlight the benefit of nursing education because our nurses represent a constant force in the care of postoperative patients, whereas anesthesia and surgical residents are transitory. PACU nurses now also page the regional team and ask for postoperative blocks to avoid using large doses of opioids in patients with abdominal pain if all other noninterventional modalities and multimodal analgesia have failed. Limitations Limitations for this study include the small number of surveys collected after the interventions and the fact that the postintervention surveys that we did receive happened to be skewed toward opioid-tolerant patients. Additionally, our intervention was focused on educating PACU nurses about multimodal pain control, despite the fact that they are not the prescribing physician and could only advocate for the use of multimodal analgesics. Nurses were allowed to consult with each other regarding the best treatment for patients and use the standard preorders to control patients’ pain. We did not apply any significance testing or any other
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statistical measure that suggests statistical significance, but we have provided simple reporting of mean differences and an absolute effect size. Nurses have many clinical responsibilities, and we did not have any funding to support a clinical researcher to collect more surveys. This limitation had a great impact on the number of surveys collected and the fact that they were collected mainly for patients who were opioid tolerant. Also, it should be noted that the CPPM has not been endorsed by a professional body and is not intended to be authoritative. It was developed to address a locally identified quality improvement issue in our hospital. As we expand this intervention, we will continually update the module and clinical pathway with the latest research. Moving forward, we are developing a sustainable eLearning module based on the workshop curriculum that will be able to introduce the interventions to more units within our institution. Many nurse managers from other units are planning to make this module part of requisite training for their nurses. We plan to disseminate the eLearning module and create a meaningful evaluation of it while we continue to assess for changes in patient satisfaction and pain control. Since the launch of this intervention, there has been a seemingly significant increase in the use of nonopioid analgesic options. We are in the process of including these multimodal recommendations in a standardized perioperative order set. We have opted to create an order set for one surgical service at a time. We have faced challenges because of differing surgeon preferences for the same surgery. This will likely be the subject of a future paper. We hope to work on a wider scale implementation and evaluation within postoperative units across the health system. Our goal is to develop an effective and sustainable pain management program that could be implemented in different settings to help improve pain management for all postoperative patients, with increased use of multimodal pain control options. Implications for Nursing Pain management education through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance.
CONCLUSIONS It is important to provide proper pain control preemptively before surgery, during a surgical procedure, and within 30 minutes of a patient’s arrival to the PACU. We were not able to statistically analyze our intervention
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because of inadequate postintervention data; however, we did discover favorable trends. Although not statistically significant, we noted an improvement in patient pain experience, especially in those with a history of opioid tolerance; a shortened PACU length of stay; reduced time to reach pain control; and improvement in overall patient satisfaction. These beneficial outcomes occurred after the combined interventions of the CPPM and nursing education program, so we cannot say if either, both, or neither was the reason
for the improved outcomes. Despite these methodologic limitations, we do believe that providers benefit from clear guidelines for multimodal pain management strategies, which is what we created within the Clinical Pathway for Pain Management. SUPPLEMENTARY DATA Supplementary data related to this article can be found online at https://doi.org/10.1016/j.pmn.2018.06.005.
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Cepeda, M. S., Carr, D. B., Miranda, N., Diaz, A., Silva, C., & Morales, O. (2005). Comparison of morphine, ketorolac, and their combination for postoperative pain: Results from a large, randomized, double-blind trial. Anesthesiology, 103(6), 1225–1232. Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., Dana, T., Bougatsos, C., & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of Internal Medicine, 162(4), 276–286. Elia, N., Lysakowski, C., & Tramer, M. R. (2005). Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology, 103(6), 1296–1304. Elliott, M. N., Lehrman, W. G., Goldstein, E., Hambarsoomian, K., Beckett, M. K., & Giordano, L. A. (2010). Do hospitals rank differently on HCAHPS for different patient subgroups? Medical Care Research and Review, 67(1), 56–73. Elvir-Lazo, O. L., & White, P. F. (2010). The role of multimodal analgesia in pain management after ambulatory surgery. Current Opinions in Anaesthesiology, 23(6), 697–703. Ferrell, B. R., & McCaffery, M. (2014). Knowledge and Attitudes Survey Regarding Pain. Retrieved from. http://prc. coh.org. Accessed November 4, 2010. Fung, D., Cohen, M. M., Stewart, S., & Davies, A. (2005). What determines patient satisfaction with cataract care under topical local anesthesia and monitored sedation in a community hospital setting? Anesthesia and Analgesia, 100(6), 1644–1650. Gauger, E. M., Gauger, E. J., Desai, M. J., & Lee, D. H. (2018). Opioid use after upper extremity surgery. Journal of Hand Surgery, 43(5), 470–479. Gonzalez-Fernandez, M., Aboumatar, H., Conti, D., Patel, A. M., Purvin, M. A., & Hanna, M. (2014). Educational gaps among healthcare providers: An institution needs assessment to improve pain management for postsurgical patients. Journal of Opioid Management, 10(5), 345–351. Gupta, S., & Atcheson, R. (2013). Opioid and chronic noncancer pain. Journal of Anaesthesiology and Clinical Pharmacology, 29(1), 6–12. Hanna, M. N., Gonzalez-Fernandez, M., Barrett, A. D., Williams, K. A., & Pronovost, P. (2012). Does patient perception of pain control affect patient satisfaction across surgical units in a tertiary teaching hospital? American Journal of Medical Quality, 27(5), 411–416.
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Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). Patients’ perception of hospital care in the United States. New England Journal of Medicine, 359(18), 1921–1931. Jiang, H. J., Lagasse, R. S., Ciccone, K., Jakubowski, M. S., & Kitain, E. M. (2001). Factors influencing hospital implementation of acute pain management practice guidelines. Journal of Clinical Anesthesia, 13(4), 268–276. Koo, P. J. (2007). Addressing stakeholders’ needs: Economics and patient satisfaction. American Journal of Health-System Pharmacy, 64(6 Suppl 4), S11–S15. Loftus, R. W., Yeager, M. P., Clark, J. A., Brown, J. R., Abdu, W. A., Sengupta, D. K., & Beach, M. L. (2010). Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology, 113(3), 639–646. Mackintosh, C., & Bowles, S. (2000). The effect of an acute pain service on nurses’ knowledge and beliefs about postoperative pain. Journal of Clinical Nursing, 9(1), 119–126. Minkowitz, H. S., Gruschkus, S. K., Shah, M., & Raju, A. (2014). Adverse drug events among patients receiving postsurgical opioids in a large health system: Risk factors and outcomes. Americanl Journal of Health-System Pharmacy, 71(18), 1556–1565. Ong, C. K., Seymour, R. A., Lirk, P., & Merry, A. F. (2010). Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: A qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesthesia and Analgesia, 110(4), 1170–1179.
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Ostling, P. S., Davidson, K. S., Anyama, B. O., Helander, E. M., Wyche, M. Q., & Kaye, A. D. (2018). America’s opioid epidemic: A comprehensive review and look into the rising crisis. Current Pain and Headache Reports, 22(5), 32. Rosenblatt, M. A. (2004). The educational effectiveness of problem-based learning discussions as evaluated by learnerassessed satisfaction and practice change. Journal of Clinical Anesthesia, 16(8), 596–601. Sunol, R., Vallejo, P., Thompson, A., Lombarts, M. J., Shaw, C. D., & Klazinga, N. (2009). Impact of quality strategies on hospital outputs. Quality and Safety in Health Care, 18(Suppl 1), i62–i68. Tan, M., Law, L. S., & Gan, T. J. (2015). Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Canadian Journal of Anaesthia, 62(2), 203–218. The Agency for Health Care Policy and Research. (1992). Acute pain management: Operative or medical procedures and trauma. Clinical Practice Guideline. AHCPR Pub. No. 92-0032. Rockville, MD: U.S. Department of Health and Human Services. The Joint Commission. (2009). Effective pain management. Tips for undergoing a complex task. The Joint Commission: The Source, 7(6). 5, 8-9. Watson, S. R., George, C., Martin, M., Bogan, B., Goeschel, C., & Pronovost, P. J. (2009). Preventing central line-associated bloodstream infections and improving safety culture: A statewide experience. Joint Commission Journal on Quality and Patient Safety, 35(12), 593–597.
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From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland. Address correspondence to Marie N. Hanna, MD, MEHP, Associate Professor, Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, 1800 Orleans Street, Zayed 8120, Baltimore, MD 21287. E-mail: [email protected] Received December 15, 2017; Revised June 4, 2018; Accepted June 26, 2018. 1524-9042/$36.00 Ó 2018 by the American Society for Pain Management Nursing https://doi.org/10.1016/ j.pmn.2018.06.005
ABSTRACT:
Background and Aims: We created a multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery. Design: A multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery. Settings: Pain management education of postanesthesia recovery room nurses through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance. Participants/Subjects: Postanesthesia recovery nurses/ postanesthesia patients. Methods: The intervention included two components: a clinical pain pathway on multimodal analgesia for both opioid-na€ıve and opioid-tolerant patients undergoing surgery and an educational program on pain management for frontline clinical nurses in the postanesthesia care unit (PACU). We measured the intervention’s impact on time to pain relief, PACU length of stay, and patient satisfaction with pain management, as measured by self-report. Results: Patient PACU surveys indicated a decrease in the percent of patients with opioid tolerance who required more than 60 minutes to achieve adequate pain relief (from 32.7% preintervention to 21.3% postintervention). Additionally, after the intervention, the average time from a patient’s PACU arrival to his or her discharge criteria being met decreased by 53 minutes and PACU stay prolongation as a result of uncontrolled pain for opioidtolerant patients decreased from 45.2% to 25.7%. The sample size was underpowered to perform statistical analysis of this Pain Management Nursing, Vol -, No - (--), 2018: pp 1-9
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improvement. Conclusions: After the combined intervention of a clinical pain pathway and interactive teaching workshop, we noted shortened PACU length of stay, reduced time to reach pain control, and improved overall patient satisfaction. Although we could not determine statistical significance, our findings suggest improved management of acute postoperative pain, especially for patients who are opioid tolerant. Because of the paucity of data, we were not able to conduct the analysis needed to evaluate quality improvement projects, as per SQUIRE 2.0. could be adopted by any institution. Ó 2018 by the American Society for Pain Management Nursing Pain management is increasingly recognized as an important aspect of high-quality care and an integral component of patient satisfaction (Baker, van der Meulen, Lewsey, & Gregg, 2007; Fung, Cohen, Stewart, & Davies, 2005). Based on the Agency for Health Care Policy and Research guidelines for acute pain management, appropriate pain management for postoperative patients contributes to earlier mobilization, shortened hospital stay, and reduced costs (The Agency for Health Care Policy and Research, 1992). Additionally, undertreatment of postoperative pain and the consequent decline in patient satisfaction can have negative effects on the economics of a health system (Koo, 2007). Pain management is a central focus of Enhanced Recovery After Anesthesia Pathways (Tan, Law, & Gan, 2015). In view of the undertreatment of postoperative pain, the American Society of Anesthesiologists established the Task Force on Acute Pain Management and published guidelines promoting standardization of procedures. The pain task force also recommended the use of patient-controlled analgesia and multimodal analgesia (American Society of Anesthesiologists Task Force on Acute Pain Management, 2012). Despite these efforts, results from clinical studies suggest that postoperative pain continues to be undertreated (Apfelbaum, Chen, Mehta, & Gan, 2003; Benhamou et al., 2008). Clinical barriers identified in this aspect of postoperative care need to be addressed because patients’ reports of satisfaction are increasingly used in public reporting, in pay-for-performance programs, and by the news media. Also, multiple studies have reported positive relationships between patients’ experiences and the quality of clinical care in U.S. hospitals (Elliott et al., 2010; Hanna et al., 2012; Jha, Orav, Zheng, & Epstein, 2008).
Previous studies have found that implementation of quality improvement strategies in hospitals has a beneficial effect on patient outcomes (Castle, Brown, Hepner, & Hays, 2005; Sunol et al., 2009). Institutional pain management programs that approach pain from a multidimensional perspective need to be developed and their impact on outcomes evaluated. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a standardized instrument and data collection methodology used to measure and publicly report patients’ experiences of hospital care (Elliott et al., 2010). The HCAHPS survey is mandated by the Centers for Medicare and Medicaid, which also oversees administration of the survey. The 2008 HCAHPS survey, which covers seven domains of care, contains 27 questions related to satisfaction with care and respondent demographic information. One of the seven domains addresses pain management with the following two questions: ‘‘During this hospital stay, how often was your pain well-controlled?’’ and ‘‘During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?’’ (Elliott et al., 2010). Studies have found a positive correlation between HCAHPS survey responses and the quality of clinical care in U.S. hospitals (Elliott et al., 2010; Hanna et al., 2012; Jha et al., 2008). Our hospital consistently ranks high in most subspecialties of medicine and surgery, but the HCAHPS survey data illustrate that it needs much improvement in the area of pain management. Previous studies have reported the importance of pain experts, such as those on an acute pain service, and that the lack of staff with expertise in pain management is a predictor of poor compliance with pain guidelines (Jiang et al., 2001; Mackintosh & Bowles, 2000). Although significant emphasis has been placed on good pain control and patient satisfaction, there is also growing recognition of the adverse effects of opioids (Center for Behavioral Health Statistics and Quality, 2015; Centers for Disease Control and Prevention, 2017; Ostling et al., 2018). The use of opioids for the treatment of chronic noncancerous chronic pain is highly controversial (Gupta & Atcheson, 2013). With increased understanding of how prescribers are contributing to the opioid epidemic, providers are turning to opioid-sparing multimodal pain control (Buvanendran & Kroin, 2009; Elvir-Lazo & White, 2010; Gauger, Gauger, Desai, & Lee, 2018). Opioids still have a place in postoperative pain control, but the opioid-sparing properties of a multimodal approach are considered preferable (Barth, Guille, McCauley, & Brady, 2017). There are many missed opportunities to use multimodal analgesia at our institution.
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INTERVENTIONS We sought to identify areas in which we could improve perioperative pain control by using our institution’s established framework of the Comprehensive Unit-Based Safety Program (CUSP). CUSP has been implemented in many units at our hospital to improve the local culture of safety, teamwork, and communication. The focus of a CUSP team is to identify and mitigate hazards in a unit. As an example, local implementation of interventions through CUSP, coupled with evidence-based central-line insertion and maintenance practices, has worked well to reduce bloodstream infections (Watson et al., 2009). We collaborated with the CUSP team to identify local barriers and implement solutions for improved pain control within our postanesthesia care unit (PACU). Using the 2009 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) selfassessment questionnaire (The Joint Commission, 2009), we asked the PACU nurses to assess how well their respective unit addresses the issue of pain control and educates unit providers on how to evaluate and treat patients’ pain. Only 29% of respondents thought that staff in their unit always receive education or training about pain assessment and management, and only 27% thought that staff has access to guidelines for pain management in their surgical units. Our initial surveys helped to identify some local barriers to improving pain management in the PACU—namely, lack of nursing education in postoperative pain control and managing pain in patients who are opioid tolerant. We received approval from the institutional review board for the collection of deidentified data using the PACU Pain Outcome Measurement Tool (Appendix D). Patient consent was not required. We implemented our intervention in a PACU that serves 17 operating rooms and sees a mixture of adult inpatient and outpatient surgical patients, including orthopedic, otolaryngology, colorectal, urology, gynecology, surgical oncology, plastics, and endocrinology cases. It is a diverse mixture of patients and cases. These are mostly extensive surgeries requiring postoperative admission or routine outpatient surgeries on patients with significant morbidity. These operating rooms perform few outpatient procedures in healthy patients because these procedures are usually performed in a separate outpatient center. The intervention included two components: (1) the creation and distribution of a Clinical Pathway for Pain Management (CPPM) with multimodal recommendations for patients undergoing surgery (Appendix A) and (2) an educational pain management workshop for perioperative nurses.
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THE CLINICAL PATHWAY FOR PAIN MANAGEMENT Based on current knowledge of multimodal pain control methods (Appendix C), the acute pain team created the CPPM for multimodal analgesia in patients undergoing surgery. The CPPM provides separate recommendations on appropriate pain interventions for opioid-na€ıve and opioid-tolerant patients. The pathway was peer reviewed by several disciplines, including anesthesia, surgery, nursing, and pharmacy. After the team reached a consensus, a one-page visual aid was created (Appendix A). Multiple copies were printed and laminated, handed out to the nurses, and taped onto the wall of the nurses’ station in one 28-bed PACU. The CPPM was also presented to the anesthesiology department during grand rounds, and copies were given to all anesthesia providers. Our rationale was that by using this clinical pathway, providers would have a guideline when placing multimodal analgesic orders, with the understanding that nurses would execute those orders based on clinical judgment. Our PACU nurses used the CPPM to remind and encourage the prescribing providers to place the multimodal medication orders. Prescribing providers place orders according to their own clinical judgment. If the surgeon did not want to prescribe nonsteroidal antiinflammatory drugs (NSAIDs), for example, they were omitted. The CPPM was not mandated; it served instead as a reminder tool and ordering guideline.
PAIN MANAGEMENT WORKSHOP We educated all 37 of the PACU nurses in the chosen area using a teaching workshop that was scheduled around their clinical shifts. In our institution, pain management education was very limited, and access to a pain management education tool was not common (Gonzalez-Fernandez et al., 2014). We decided to move away from traditional classroom lectures and introduce interactive teaching through cases. Three case scenarios were prepared and revised by a group of pain faculty. One pain faculty member, one fellow, and two residents recorded videos in patient rooms. Cases reinforced the learning of multimodal analgesia and its benefit in pain management. We presented the cases in a format of problem-based learning (Rosenblatt, 2004) to PACU nurses. The nurses were first provided with the rationale for treatment of postoperative pain. Instructors presented a review of the morbidity associated with inadequate pain control and the corresponding literature citations. Next, nurses were introduced to the benefits of multimodal analgesia and taught the mechanism of
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action, indications, and contraindications of acetaminophen, gabapentin, pregabalin, NSAIDs, celecoxib, opioids (particularly methadone), and ketamine. Finally, the instructor showed the three videos and asked questions (Appendix B); nurses were given the opportunity to answer the questions and receive correct explanations in a group discussion that was guided by slides. Case 1 introduced the effective use of epidural analgesia as part of multimodal therapy, case 2 introduced the importance of using peripheral nerve catheters in orthopedic patients, and case 3 presented pain treatment options in opioid-tolerant patients (Appendix B). Nurses attended the workshops voluntarily, were scheduled for either before or after their clinical shifts, and were given 10 minutes at the end of every workshop to ask questions. Three to five nurses were present at each of the six workshops that we held. Two months after the workshop, all 37 PACU nurses were asked to complete the Knowledge and Attitudes Survey Regarding Pain Management that we had revised for use as an evaluation tool to assess health care professionals’ knowledge of pain management (Ferrell & McCaffery, 2014). We also asked the PACU nurses to assess how well their respective unit addressed the issue of pain control and educated staff on how to evaluate and treat patients’ pain. We used the 2009 JCAHO self-assessment questionnaire (The Joint Commission, 2009). We also asked the nurses to evaluate the pain workshop and to provide feedback.
EVALUATION OF INTERVENTION SUCCESS To evaluate the effect of the interventions on postoperative pain control, we conducted patient-centered assessments of pain management in the PACU using a combined nurse-patient survey (Appendix D). Patients
responded to questions regarding their perception of pain control while they were in the PACU. Surveys were conducted by the PACU nurses for 6 months before implementation of the interventions and then for another 6 months beginning 2 months after the interventions were complete. The survey consisted of two parts. Questions in Part 1 related to pain management in the recovery room and were answered by the nurse caring for the patient (questions 1-14, Appendix D). Information gathered in this part included (1) the length of time for the patient to experience pain relief after arrival to the PACU and (2) the duration of time from PACU admission to the discharge criteria being met. In Part 2, a nurse not participating in the patient’s care asked the patient to respond to questions regarding his or her perception of pain control (Appendix D, Part 2). These questions were asked immediately before discharge from the PACU. Two of these questions were very similar to the pain-related questions in the HCAHPS survey (Elliott et al., 2010): ‘ How often was your pain well controlled?’’ and ‘ How often did staff do everything they could to help with pain control?’’ Before the intervention, we collected 399 PACU patient-centered surveys. The results indicated that 82 patients (20.5%) had a history of opioid tolerance, defined as use of opioids for at least 2 weeks before surgery (question 1 in Appendix D). Patients with a history of opioid tolerance differed from opioid-na€ıve patients on a number of metrics (Table 1). More than half of opioid-tolerant patients (51.3%) reported a PACU admission pain level of $7 out of 10 compared with 28.5% among other patients. In addition, 32.7% of opioid-tolerant patients required more than 60 minutes until pain relief, whereas only 11.2% of opioidna€ıve patients required that much time. The PACU length of stay was longer for opioid-tolerant patients (3 hours and 37 minutes) than for opioid-na€ıve patients (3 hours and 9 minutes). Furthermore, 45.2% of opioidtolerant patients had their PACU stay prolonged
TABLE 1. Preintervention Survey of Patient Experience with Pain Control in Postanesthesia Care Unit Stratified by History of Opioid Tolerance History of Opioid Tolerance Parameter Pain score on arrival to PACU was 7/10 or greater Pain was always well controlled Required more than 60 min for pain relief after PACU arrival Time from PACU arrival to meeting of discharge criteria PACU stay was prolonged because of uncontrolled pain PACU ¼ postanesthesia care unit.
No (n ¼ 317) 28.5% 69.5% 11.2% 3 h:9 min 15.7%
Yes (n ¼ 82) 51.3% 55.6% 32.7% 3 h:37 min 45.2%
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TABLE 2. Survey of Opioid-Tolerant Patients’ Experience with Pain Control in Postanesthesia Care Unit Before and After Intervention Parameter
Before Intervention (n ¼ 82)
After Intervention (n ¼ 87)
Reported that pain was always well controlled in PACU Required more than 30 min for pain relief after PACU arrival Required more than 60 min for pain relief after PACU arrival PACU stay was prolonged because of uncontrolled pain Time from PACU arrival to meeting of discharge criteria
55.6% 54.5% 32.7% 45.2% 3 h, 37 min
68.7% 43% 21.3 % 25.7% 2 h, 44 min
PACU ¼ postanesthesia care unit.
because of uncontrolled pain, compared with 15.7% of other patients. Unfortunately, we received only 102 postintervention surveys. This number was inadequate to power statistical analysis of the impact of our interventions. Of the 102 postintervention surveys, 87 were for patients with opioid tolerance. Although we were unable to determine statistical significance, we did identify trends in the data. Because the majority of postintervention surveys were from opioid-tolerant patients, we chose to look at trends in this group only. When we compared data from opioid-tolerant patients before and after the interventions, we found that the percentage of patients who reported that pain was always controlled increased from 55.6% before the intervention to 68.7% after the intervention. Additionally, we found a decrease in the
percentage of patients who required more than 60 minutes for pain relief in the PACU (from 32.7% to 21.3%) and a 53-minute decrease in the average time from a patient’s PACU arrival to his or her discharge criteria being met (from 3 hours, 37 minutes to 2 hours, 44 minutes; Table 2). Two months after the workshop, 34 out of 37 PACU nurses (91%) completed the knowledge questionnaires and JCAHO survey in pain management. Knowledge questionnaire scores improved to an average of 69%, compared with 49% in our study conducted 2 years earlier (Gonzalez-Fernandez et al., 2014). The JCAHO self-assessment results (Table 3) indicated that more than 90% of PACU nurses selfassessed their working unit to have a standard protocol and guidelines for pain management practice. More than 80% believed that their staff are regularly
TABLE 3. Summary of Nurse Responses to the JCAHO Self-Assessment Questionnaire Self-Assessment Questions Does your surgical unit document ongoing pain assessment and interventions? Does your surgical unit have a written pain protocol or standard of practice? Does your surgical unit’s method for pain documentation place pain intensity in a highly visible or prominent position that encourages regular view by all staff? Does your organization have standards or guidelines that define the maximum acceptable pain? Does your surgical unit’s staff have access to guidelines for pain assessment and management? Is staff regularly educated or trained about pain assessment and management? Does your organization maintain a supply of patient education materials for pain management? Are all patients educated about pain and the importance of effective management? Is pain included in the discharge planning process? Does your surgical unit ensure the communication of pain management when a patient transitions across health care settings? Have surgical unit leaders made pain a performance improvement priority? Is the assessment and management of pain integrated into competency and performance evaluations for staff and licensed independent practitioners? JCAHO ¼ The Joint Commission on Accreditation of Healthcare Organizations. *All data are shown as n (%).
Response of Always or Mostly Done (n ¼ 34)* 34 (100) 33 (97) 30 (88) 30 (88) 34 (100) 28 (82) 28 (82) 30 (88) 32 (94) 28 (82) 29 (85) 25 (74)
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educated and trained about pain assessment and management, that all patients are educated about pain and the importance of effective management, and that their unit leaders made pain a performance improvement priority (Table 3). More than 90% of the nurses evaluated the workshop as being extremely helpful and said that it made them comfortable managing pain in the PACU. More than 50% of respondents believed that repeating similar workshops would be helpful. Although the changes after the intervention seem favorable, we did not gather enough postintervention data to perform statistical analysis and therefore cannot conclude that the intervention was associated with a statistically significant improvement.
DISCUSSION The CPPM was created by a consensus of clinicians at our institution after careful literature review and has not been tested for effect on patient outcomes. The combined intervention of the CPPM and interactive teaching workshop appeared to have a favorable effect on the institution’s management of acute postoperative pain, especially for patients who were opioid tolerant. The preintervention survey results indicated that opioid-tolerant patients spent more time in the PACU and were less satisfied with their pain control than opioid-na€ıve patients. After the intervention, self-reports of pain control improved, fewer patients required more than 60 minutes for pain relief in the PACU, and PACU stays were shorter, although we cannot say if these changes are statistically significant. Two months after the workshops, we noted improvements in nurses’ knowledge of pain control and perception of unit standards on pain education and resources. Knowledge questionnaire scores improved to an average of 69% (from 49%). Nurse perceptions of the institution’s pain management guidelines, pain education practices, and commitment to the treatment of pain also increased from 29% in the previous study (Gonzalez-Fernandez et al., 2014) to 90% after the intervention. Although PACU nurses do not write any orders, they are important decision makers for patient pain control. They are the first line of patient care in the immediate recovery period after surgery, and they have the potential to be strong patient advocates. When we began our intervention, the concept of multimodal analgesia was new to the PACU nurses and ordering providers. The CPPM served as a reminder and educational tool regarding multimodal options, dosing, indications, and contraindications. The CPPM was not a required part of an order set, but we believe that
having the CPPM in hand did empower our PACU nurses to request these on patients’ behalf when they thought appropriate. A provider’s effort to pursue all possible multimodal agents to control a patient’s pain can strongly influence that patient’s perception of pain control. We previously examined the relationship between a patient’s perceptions of pain control and overall satisfaction with care (Hanna et al., 2012). Our results indicated that a patient’s perceptions of pain control and of staff’s efforts to control pain are associated with overall satisfaction scores. We also found that patients were more likely to rate their overall hospital experience highly if they perceived that their health care providers were doing everything they could to help control the pain and that their pain was well controlled. Interestingly, after we adjusted for age, sex, nurses’ courtesy, and physicians’ courtesy (communication), staff performance in managing pain was a stronger predictor of satisfaction than pain control itself. The odds of a patient being satisfied were 4.86 times greater if pain was always controlled as opposed to not always controlled and 9.92 times greater if staff performance was always appropriate with their care as opposed to not always appropriate with their care (Sunol et al., 2009). Hence, educating nurses about best treatment practices for pain control can substantially improve patients’ perceptions of the postoperative period. Nurses who took the knowledge and selfassessment questionnaires had positive comments regarding the effect of the workshop on their daily practice. Samples of these comments include the following: ‘‘We should have more teaching in pain management cases’’; ‘‘This learning made me more comfortable with the use of multimodal drugs in pain management’’; ‘‘I am not reaching out for narcotics like I used to for my patients’’; and ‘‘I feel all surgical residents need to attend these workshops.’’ The practice of perioperative pain management has changed significantly in the last two decades with the use of regional anesthesia, multimodal analgesia, and acute pain teams. However, acute pain management is extremely challenging in opioid-tolerant patients, especially in those with drug-seeking behavior (Aronoff, 2000; Carroll, Angst, & Clark, 2004; Chou et al., 2015). A comprehensive multimodal analgesic plan that includes regional analgesia may decrease opioid requirements in these patients (Minkowitz, Gruschkus, Shah, & Raju, 2014; Ong, Seymour, Lirk, & Merry, 2010). The use of nonopioid analgesics, including acetaminophen and NSAIDs, can help to decrease pain from inflammation and reduce subsequent opioid use (Elia, Lysakowski,
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& Tramer, 2005). Ketorolac is particularly useful because it has been found to decrease morphine use and morphine-related side effects (Cepeda et al., 2005). NMDA (N-methyl-D-aspartate) receptor antagonists such as ketamine potentiate the analgesic effects of opioids and may decrease opioid tolerance (Loftus et al., 2010). In randomized controlled studies, intraoperative administration of intravenous ketamine decreased opioid requirements after surgery (Loftus et al., 2010). In this project, we noted a favorable trend in nurse education and the pain control of opioidtolerant patients in the PACU. We did not have any data to suggest that teaching the workshop alone, without the CPPM, had an impact on nurses’ knowledge or on patient care. Nurses are vital members of our team, and, as such, their knowledge of the physiology and literature behind the modern-day approach to pain management is crucial. Nurses spend more time with patients than physicians do and are relied on to manage patients with significant postoperative pain. Our past surveys (Gonzalez-Fernandez et al., 2014) indicated that perioperative nurses had scant knowledge about pain management, pain medications, and the research supporting the use of epidural catheters and peripheral nerve blocks as part of multimodal analgesia. In our institution we laminated the CPPM and distributed it among our preoperative and PACU staff. The nursing staff has embraced the pathway. We have anecdotal reports that the nurses used the CPPM to remind residents to put in orders for multimodal medications. Such actions highlight the benefit of nursing education because our nurses represent a constant force in the care of postoperative patients, whereas anesthesia and surgical residents are transitory. PACU nurses now also page the regional team and ask for postoperative blocks to avoid using large doses of opioids in patients with abdominal pain if all other noninterventional modalities and multimodal analgesia have failed. Limitations Limitations for this study include the small number of surveys collected after the interventions and the fact that the postintervention surveys that we did receive happened to be skewed toward opioid-tolerant patients. Additionally, our intervention was focused on educating PACU nurses about multimodal pain control, despite the fact that they are not the prescribing physician and could only advocate for the use of multimodal analgesics. Nurses were allowed to consult with each other regarding the best treatment for patients and use the standard preorders to control patients’ pain. We did not apply any significance testing or any other
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statistical measure that suggests statistical significance, but we have provided simple reporting of mean differences and an absolute effect size. Nurses have many clinical responsibilities, and we did not have any funding to support a clinical researcher to collect more surveys. This limitation had a great impact on the number of surveys collected and the fact that they were collected mainly for patients who were opioid tolerant. Also, it should be noted that the CPPM has not been endorsed by a professional body and is not intended to be authoritative. It was developed to address a locally identified quality improvement issue in our hospital. As we expand this intervention, we will continually update the module and clinical pathway with the latest research. Moving forward, we are developing a sustainable eLearning module based on the workshop curriculum that will be able to introduce the interventions to more units within our institution. Many nurse managers from other units are planning to make this module part of requisite training for their nurses. We plan to disseminate the eLearning module and create a meaningful evaluation of it while we continue to assess for changes in patient satisfaction and pain control. Since the launch of this intervention, there has been a seemingly significant increase in the use of nonopioid analgesic options. We are in the process of including these multimodal recommendations in a standardized perioperative order set. We have opted to create an order set for one surgical service at a time. We have faced challenges because of differing surgeon preferences for the same surgery. This will likely be the subject of a future paper. We hope to work on a wider scale implementation and evaluation within postoperative units across the health system. Our goal is to develop an effective and sustainable pain management program that could be implemented in different settings to help improve pain management for all postoperative patients, with increased use of multimodal pain control options. Implications for Nursing Pain management education through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance.
CONCLUSIONS It is important to provide proper pain control preemptively before surgery, during a surgical procedure, and within 30 minutes of a patient’s arrival to the PACU. We were not able to statistically analyze our intervention
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because of inadequate postintervention data; however, we did discover favorable trends. Although not statistically significant, we noted an improvement in patient pain experience, especially in those with a history of opioid tolerance; a shortened PACU length of stay; reduced time to reach pain control; and improvement in overall patient satisfaction. These beneficial outcomes occurred after the combined interventions of the CPPM and nursing education program, so we cannot say if either, both, or neither was the reason
for the improved outcomes. Despite these methodologic limitations, we do believe that providers benefit from clear guidelines for multimodal pain management strategies, which is what we created within the Clinical Pathway for Pain Management. SUPPLEMENTARY DATA Supplementary data related to this article can be found online at https://doi.org/10.1016/j.pmn.2018.06.005.
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Postoperative Pain Management Program
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