SAFE USE OF OPIOIDS NATIONAL COLLABORATIVE LEARNING SESSION ZERO
Judy Leader Nurse Practitioner Pain Management MidCentral Health 2014
OPIOID ARE INDICATED FOR…
MCH PAIN MANAGEMENT REVIEW 1999 Develop a multidisciplinary team to promote best
practice in pain management Staff Pain Management Knowledge and Attitude
Study Patient Pain Management Satisfaction Survey Audits of Clinical Practice Audits of Emergency Dept Admission Trends Introduction of Pain as Fifth Vital Sign
THE TEAM Clinical Director-Rehab Clinical Nurse Specialist-Child Health Nurse Clinician-Acute Pain Service Clinical Director-Hospice Clinical Nurse Specialist-Palliative Care Clinical Coordinator-After hours Clinical Pharmacist Complementary Health Midwifery Physiotherapy Clinical Nurse Specialist-Elder Health Alcohol and Drug Service Occupational Health Professional Pharmacy Advisor Orthopedics General Practice
MISSION The MidCentral Health Multidisciplinary Pain Management
Team promotes safe, timely and effective relief of pain and suffering for all patients by advancing pain
management skills, knowledge and attitudes within our community.
AGREED VALUES
Patient first Equity Quality
KEY GOALS
Advance health Build capacity
Track performance Measure outcomes
BASELINE DATA
20-25% of admissions identify pain as primary complaint.
88.7 % of patients stated they experienced pain.
Only 7.2% of patients had documented evidence of pain assessment.
Staff knowledge deficits in assessment, addiction, pharmacology and physiology/pathophysiology of pain.
No common language.
LANGUAGE UTILISED TO DOCUMENT PATIENT’S LEVEL OF COMFORT
Appears comfortable Regular analgesia given Nil complaints of discomfort c/o pain tramadol/panadol given as charted Given regular pain relief Complaining of pain +++ Analgesia as charted with effect No mention of pain Codeine, morphine, panadol given
KEY STRATEGIES; STANDARDISE AND PROMOTE PAIN ASSESSMENT
PAIN ASSESSMENT AT MCH Cause and physiological
response Location(s) Intensity (at rest and on
movement) Quality Onset and duration Precipitating factors Modifying factors Psychological response Behavioral response Re-assessment
MIDCENTRAL HEALTH PAIN ASSESSMENT AUDITS 2001-2003
020406080
100
Cause
Locatio
n
Inte
nsity
Qualit
y
Onse
t/Dura
tion
Precipita
ting F
x
Modify
ing F
x
Psych
ologi
cal R
x
Behavioura
l Rx
Rea
sses
smen
t
Recommended components of pain assessment
Percentage of clinicians
able to identify
component
2001
2002
2003
IMPLEMENT PAIN AS THE 5TH VITAL SIGN
Toolkit for Implementation
FIFTH VITAL SIGN AUDIT-THE PROCESS
10 sets of clinical notes randomly selected from 11 clinical areas 2002-2014, (sample 110 pts).
MidCentral Health Nursing Assessment form. MidCentral Health Observation chart. Evidence of pain assessment in previous 24hrs
clinical notes, all disciplines. Evidence of analgesia administered (treatment
chart). Evidence of evaluation of analgesia’s efficacy.
PAIN ASSESSMENT-CLINICAL
0
20
40
60
80
100
2002 2006
DEVELOP/ PROMOTE PHARMACOLOGICAL PAIN MANAGEMENT GUIDELINES
PLAN, FACILITATE AND EVALUATE MULTIDISCIPLINARY PAIN MANAGEMENT EDUCATION
Senior Clinicians/Management Pain Management workshops.
Monthly multidisciplinary forums. Annual Pain Management Awareness Week New Zealand Pain Society. Australian National
Institute for Clinical Studies, National Health Committee.
DEVELOP PAIN MANAGEMENT PUBLIC AWARENESS INITIATIVES
Chronic Pain Support Foundation. Pain Management Awareness Week. Newspaper articles, public speaking. Liaison with local providers of pain management
services.
DEVELOP AGREED STANDARDS OF PAIN MANAGEMENT Recognise the patients rights to appropriate assessment and
management of their pain. Determine and ensure staff competency in pain assessment
and management, and address pain management in the orientation of all new staff.
Assess existence, nature, intensity of pain in all patients. Record results of pain assessment in a way that facilitates
regular reassessment and follow up. Establish policies and procedures supporting appropriate
prescription or ordering of pain medications. Monitor patients continuously post procedure for pain
intensity and quality, and response to treatments. Educate patients and their families about effective pain
management practices. Address patient needs for pain management in the discharge
planning process. Collect data to monitor the appropriateness and effectiveness
of pain management. JACHO 1999
EXPERIENCE OF PAIN
0
20
40
60
80
100
pts pain
2002
2005
PAIN MANAGEMENT
0
20
40
60
80
100
want/need Tx receive Tx
2002
2005
PATIENT SATISFACTION PAIN MANAGEMENT 02-05
020406080
100
NurseTx Pain
02
NurseTx Pain
05
DoctorsTx Pain
02
DoctorsTx Pain
05
OverallSatis 02
OverallSatis 05
DOCUMENTATION OF PAIN ASSESSMENT PRIOR TO AND FOLLOWING ANALGESIC INTERVENTION
IS VITAL TO ENSURE EFFECTIVE HEALTH OUTCOMES
0
10
20
30
40
50
60
70
80
90
100
Ward A Ward B Ward C Ward D Ward E Ward F Ward G Ward H Ward I Ward J Ward K
Per
cent
age
com
plet
e
Clinical area
Fifth Vital Sign; Assessment all areas, 2012-2014
201220132014
0
10
20
30
40
50
60
70
80
90
100
Ward A Ward B Ward C Ward D Ward E Ward F Ward G Ward H Ward I Ward J Ward K
Per
cent
age
com
plet
e
Clinical area
Fifth Vital Sign; Observation chart all areas 2012-2014
201220132014
0
10
20
30
40
50
60
70
80
90
100
Ward A Ward B Ward C Ward D Ward E Ward F Ward G Ward H Ward I Ward J Ward K
Per
cent
age
com
plet
e
Clinical area
Fifth Vital Sign; Pain as focus of care, 2012-2014
201220132014
The aim is to have both bars matching
0
10
20
30
40
50
60
70
80
90
100
Ward 23 Ward 24 Ward 25 Ward 26 Ward 27 Ward 28 Ward 29 Star 1 Star 2 Ch Ward WSU
Per
cent
age
com
plet
e
Clinical area
Fifth Vital Sign; Intervention/evaluation all areas 2014
interventevaluation
(PGY1 HOUSE SURGEONS-2013)
What is the first line strong oral opioid? 70% Oxycontin/norm Is laxative and antiemetic routinely prescribed? 60% Yes Is Oxycontin/norm stronger, weaker, same strength as
oral morphine? 80% wrong Indications for Oxycontin/norm use? 80% did not know Do you limit amount patient discharged on (excluding
palliative care patients) ? 80% Yes Do you talk to GP and have discharge plan? 80% No
THE MIDCENTRAL HEALTH APPETITE/NAUSEA SCALE PROJECT 2012
It’s not about the number!
A COMPLAINT REGARDING THE FEEDING OF A PATIENT INITIATED A
QUALITY IMPROVEMENT PROJECT THROUGH THE MIDCENTRAL HEALTH NURSING CLINICAL
PRACTICE ACTION GROUP (CPAG).
THE NURSING PROCESS WAS UTILIZED AS A FRAMEWORK IN THIS PROJECT
STEP 1. ASSESS THE SITUATION PATIENTS IN HOSPITAL LOSE WEIGHT. NURSES DO NOT UTILISE A STANDARDISED APPROACH TO DISCUSS, DOCUMENT AND MONITOR APPETITE OR NAUSEA.
Data sourced to inform our critical thinking: •Documentation audit •Patient survey •Literature review •Working groups •Assessment and Reliability Taskforce data •Focus groups •Staff feedback
PATIENTS WERE INTERVIEWED. THEIR DOCUMENTATION WAS ALSO REVIEWED
Patients complained of •Anticipatory nausea •Intermittent nausea •Constant nausea •Retching •Vomiting •No appetite
Effect on patients appetite •No effect on appetite •Patient eating with nausea •Patient drinking with nausea •Patient eating and drinking •No appetite unrelated to nausea
None of these patients had regular antiemetic charted PRN medications prescribed included Metocloprimide 10mg,
Ondansetron 4-8mg, Domperidone 10mg, Cyclizine, 50mg none were administered regularly.
SUMMARY-APPETITE &NAUSEA AUDIT JUNE 2011
Multiple factors influence appetite
Food (smells, presentation) Mood Lack of exercise Lack of fresh air Constipation Medications Treatments (e.g. radiotherapy,
surgery) Failure to administer anti-emetics as
prescribed/required Dry mouth/ sore mouth
Multiple factors influence nausea
May be anticipatory, intermittent, constant
May be associated with eating, drinking, movement, medications and anxiety
May or may not be associated with retching or vomiting
Tendency towards PRN rather than regular prescription/administration of anti emetic
Step 2.Diagnosis: Naming the problem •Our current observation form did not support documentation •Yes/no response provided little useful data to monitor common symptom progression (Feedback to working group/CPAG)
Step 3. Planning:
What are we going to do and how? We needed to identify a tool which will improve the assessment and management of our patients appetite and nausea
AIM OF THE TOOL: TO PROVIDE A COMMON LANGUAGE TO DISCUSS NAUSEA AND APPETITE.
AN ASSESSMENT SCALE WAS DEVELOPED AND PILOTED BY STAFF IN WARDS 23, ONCOLOGY AND 24, ORTHOPAEDICS FOCUS GROUPS FACILITATED, FEEDBACK FORMS COMPLETED AND SUMMARIZED TOOL AMENDED FURTHER TO INCORPORATE NURSING FEED-BACK REVISED TOOL PILOTED & AGAIN FEEDBACK SOUGHT AND COLLATED
STEP 4. IMPLEMENTATION: MAKING IT HAPPEN MCH OBSERVATION CHART HAS BEEN REDESIGNED. A SCORE DEVELOPED BY MCH NURSES IS NOW REQUIRED WHEN DOCUMENTING APPETITE & NAUSEA.
The MidCentral Health Appetite and Nausea scale
ID cards have been developed and are available from materials management to promote the assessment of appetite and nausea (Order nos 740116)
THE PATIENT IS NOT
REQUIRED TO PICK A NUMBER HOWEVER THE PATIENTS REPORT WILL
INFORM THE SCORE
A poster has been developed to assist the marketing and promotion of this initiative.
It is available to download from the nursing portal, follow CPAG link
THE SCALE IS INTENDED TO IMPROVE COMMUNICATION WHICH WILL
INFORM ASSESSMENT, MONITORING AND EVALUATION OF APPETITE AND
NAUSEA OVER TIME.
POTENTIAL CONTRIBUTING FACTORS TO CONSIDER… •Chemicals-drugs such as opioids, steriods, antibiotics •Treatments-radiation therapy, chemotherapy •Biochemical imbalance-Hypercalcemia, hyponatremia uraemia, endocrine imbalance •Toxins-infection, ischaemic bowel •GI tract disturbance-ileus, constipation, obstruction •Psychological factors-fear, anxiety, pain Chose a case study from the following and discuss with colleagues
QUESTIONS TO CONSIDER.. •Based on your assessment what could be contributing to your patients appetite/nausea? •What is your patients appetite/nausea score? •What interventions will you consider & why? •How will you evaluate the efficacy of these interventions and record your findings? •Who could you ask for help?
CASE STUDY 1
68 year old male returned from OT last night following a total hip replacement with PCA in situ. At 7.30 am the following morning the patient rates his pain score at 5/10 and states he has no appetite and does not feel like eating breakfast. No nausea reported.
CASE STUDY 2
24 year old female recently diagnosed with breast cancer. Presents with persistent nausea. Has not eaten for three days. Has tried Metoclopramide 10mg with no effect. No complaints of pain.
FEEDBACK FROM NURSES INVOLVED IN PILOT
Ensures that I monitor patients’ eating habits
Engages conversation around appetite Allows for measurement of patients
perception of nausea/appetite Good for documentation as focus charting Focus awareness on lack of appetite Makes you more aware Picks up patients with poor appetite
STEP 5. EVALUATION: HAS OUR PRACTICE CHANGED? FURTHER DATA SOURCED TO MEASURE PROGRESS AGAINST BASELINE. REPORT TO STAKEHOLDERS REPEAT PROCESS AS NECESSARY TO ENSURE CONTINUOUS QUALITY CYCLE MAINTAINED
Thanks to those who participated in this project
Staff of Ward 23 & 24
OTHER MCH OPIOID RELATED INITIATIVES Integration of e-pharmacy Integration of Safer Sleep Review of Acute Pain Service documentation NP outreach model of care
PAIN & DISTRESS