TARGETING PAIN IN OLDER PEOPLE IN THE ACUTE CARE SETTING

Transcription

1 TARGETING PAIN IN OLDER PEOPLE IN THE ACUTE CARE SETTING Isabel Higgins Professor of Nursing Older Person Care, Collaborating Centre for Older Person care: RCGHA School of Nursing and Midwifery, University of Newcastle & CPOD Hunter New England Health

2 TARGETING PAIN TEAM Caroline Phelan CNS Fiona Hodson CNC 3 Peter Summons Senior lecturer TUN Jeanene Douglas CNS Linda Ritchard CNC 3 Debbie Bruce CNS OPAC Glody Mabbott RN Pauline Dobson CNC 3

3 Funding support Nursing and Midwifery Office NSW Health Department of Medicine, John Hunter Hospital, Hunter New England Health, New South Wales, Australia.

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6 The Campus Environmental Bush-Land campus Large grounds

7 The Location City/beach University

8 The location

9 The location

10 The location

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12 The location

13 The problem of pain Pain is common in older people (Ferrell et al., 1995 Madjar & Higgins, 1996, 2004) Persistent pain is common (Ferrell et al., Madjar & Higgins, 1996, 2004) Multiple sources and types of pain are common (Madjar & Higgins, 1996, 2004) Hospitalised older patients experience high levels of unrelieved pain (Yates et al., 1998; NICS, 2003)

14 The problem of pain There are many barriers to assessment of pain in older people Older people under-report their pain Fear being labelled a complainer They regard pain as a part of growing old Fear of addiction Perceive that health care workers too busy No expectation for pain relief Poor knowledge of staff about pain and pain relief Attitudes of staff towards older people and pain (Blomquist et al., 2003; Brockopp et al., 1996; Madjar & Higgins, 1996, 2004)

15 The problem of pain Assessment of pain is rarely documented (Idval et al., 2002) Staff often underestimate and under-treat pain in the older person (Idval et al., 2002) Precipitating factor for delirium (Inouye, 2001) Pain may hinder recovery and prolong hospitalization associated with depression, anxiety, cognitive impairment, decreased appetite, weight loss, and disturbances to sleep, gait, general activity, mood and relationships with other people. Strassels, Chen & Carr, 2002

16 The problem of pain Organisations do not make pain management part of their core business Health professionals outside of pain services do not assess or document pain NICS, 2003

17 Setting for the study Large 600 bed tertiary referral hospital in regional NSW Australia 32 bed mixed medical and surgical ward Specialising in neurosurgical and neuromedical patients Incorporating a stroke unit

18 Purpose of the study To profile the management of pain in older people in the acute care setting

19 Aims of the study To determine whether a multidisciplinary education program designed to focus on pain management in older people improves the detection and management of pain in this group To evaluate the project using pre and post audit mechanisms and qualitative interviews with patients and staff

20 Study design Pre post audit evaluation study on one ward Six phases Pre study chart audit (n=20) Clinical guideline development Multidisciplinary pain education program development Promotional media development Targeting pain Post chart audit (n=20) Patient interviews (n=4) & survey (n=10) Focus group with staff (n=3)

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22 Education program Multidisciplinary Targeted all discipline groups For nurses relied on train the trainer following 20% target Focused on pain assessment and management Documentation Range of assessment tools provided

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24 Pain let me know

25 Division of Medicine Division of Medicine Currently Targeting Currently Targeting

26 Chart audit data Age Gender Relevant medical history Diagnosis Pain assessment Analgesia, nature and type, efficacy Nurse initiated strategies

27 Participants Older adults over 65 years admitted to neuro medical/surgical ward Able to give informed consent Consenting staff: Nurses Physiotherapists Speech pathologists Medical officers

28 Data analysis Descriptive statistics - chart audit data Content analysis - qualitative data

29 Findings chart audit Increased pain assessment from pre chart audit by nurses Increased documentation in progress notes and observations charts Increased use in analgesics paracetamol Efficacy noted Non pharmacological approaches noted pre or post audit

30 Chart audit 70% 60% 50% 40% 30% 20% 10% 0% Pain Assmnt on Admission Pain Assmnt during Admission Analgesia given in last 24hrs Documentation of Efficacy Multimodal Analgesia Used Pre Education Audit Post Education Audit

31 Patient survey data 50% of patients received information about pain management The average pain score was % of patients said pain interfered with ADLs 30% of patients said they did not have to ask for analgesia 50% of patients waited less than 10 minutes for pain relief when it was requested. 70% of patients were satisfied with pain management

32 Patient interview There was a high degree of satisfaction with care and attention to pain The badges worn by nursing staff were noticed by family and staff: it sort of allows you to talk about pain Patients use a range of strategies at home to relieve pain including distraction

33 Focus group interview The badges were useful because they drew attention to pain Posters were not noticed as readily as the badges Participants suggested self directed learning packages allow staff to pace their own learning Case based scenarios were thought to be an appropriate approach to learning about pain Short in-service approaches were not as effective as extended education programs A range of strategies are used by nurses to alleviate pain including positioning and re positioning the patient

34 Findings - focus group I remember the in-service but I don t remember taking anything away from it I mean you know, we got the badge and we were told to be more on the lookout for patient s pain. And that s what I did. And that s what you did. So, was there a presentation around what sorts of pain tools to use? I don t remember. It wasn t something that like stuck in my mind, and I thought was really good or really bad, I just

35 Discussion The findings of this study show a slight improvement in the assessment and management of pain in older people. Using an educational approach supported by visual media may be effective. In particular, the use of badges serve to profile pain as a focus of care. Patient survey data suggest that patients continue to have high levels of pain despite their reported satisfaction. There may be a range of self initiated pain relief strategies used by patients that nurses could facilitate during hospitalisation. Alternative educational approaches/strategies to pain education were suggested by participants.

36 Recommendations The pilot study highlighted several design issues including the need to; refine the audit tool to ensure validity of data collected engage medical and allied Health staff in the research process from the outset review and re design the education program and general approaches used to include non pharmacological approaches to pain management, case studies, self directed learning supplemented with extended education days. encourage use of algorithms redesign badges to be more visually appealing explore alternative approaches to placement of targeting signs such as computer screen saver. develop localised pain guidelines for the management of pain in older people in the acute care setting

37 References Blomqvist, K, (2003) Older people in persistent pain: nursing and paramedical staff perceptions and pain management. Journal of Advanced Nursing,41, Brockopp, D., Warden, S., Colclough, G. & Brockopp, G. (1996). Elderly people s knowledge of and attitudes to pain management. British Journal of Nursing, 5(9) Chodosh J., Ferrell B., Shekelle M., & Wegner M. (2001. Quality indicators for pain management in vulnerable elders. Annals of Internal Medicine 135(8): Ferrell, B. A., Ferrell, B. R. & Rivera, L. (1995). Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management 10(8), Idval, E. & Ehrenberg, A. (2002) Nursing documentation of postoperative pain management. Journal of Clinical Nursing, 11, Inouye, S., Foreman, M., Mion, L., Katz, K., & Cooney, L. J Nurse's recognition of delirium and its symptoms. Archives of Internal Medicine, 161(Nov 12), Higgins, I., Madjar, I., & Walton, J. (2004) Chronic pain in elderly nursing home residents: The need for nursing leadership. Journal of Advanced Nursing. 12, Madjar, I. & Higgins, I. (1996a, August). The adequacy of pain relief measures in elderly nursing home residents. Poster session presented at the 8th World Congress on Pain, Vancouver, Canada. Potter V., Wiseman C., Dunn S., & Boyle F (2003) Patient barriers to optimal cancer pain control. Psycho-oncology, 12: Strassels, S, Chen, C (2002) Postoperative analgesia: economics, resources use, and patient satisfaction in an urban teaching hospital, Anesthetics and Analgesia, 94: Yates P., Edwards H., Fentiman B., Najman J., Nash R et al., (1998). The prevalence of pain amongst hospital in patients. Journal of Clinical Nursing, 7: National Institute of Clinical Studies (2003), Australia.

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