Conflict of Interest Disclosure. Are Pain Ratings Irrelevant?

Transcription

1 Implementation of the CAPA (Clinically Aligned Pain Assessment) Tool: Pain is More than Just a Number Debra J. Drew, MS, ACNS-BC, RN-BC, AP-PMN Conflict of Interest Disclosure Author s Conflict of Interest No Conflicts of Interest Objectives Learners will be able to: 1.Discuss the concept of pain assessment as a social transaction between patient and clinician. 2.Summarize the outcomes of University of Minnesota Health s implementation of CAPA. 3.Describe the lessons learned from implementing a complex and culturechanging project. Impetus for Change at University of Minnesota Medical Center 2012 Low patient pain satisfaction scores (HCAPH) Anticipation of effect of Centers for Medicare and Medicaid s Value-Based Purchasing plan Reimbursement based in part on satisfaction with care. State of Minnesota, an average of 70% of patients reported satisfaction with pain management scores (MDH, 2014) Staff dissatisfied with current numeric pain scale Are Pain Ratings Irrelevant? Noted that fellow pain and palliative care colleagues didn t always ask about pain intensity using the numeric scale In 2015, Short Survey of APS members, N=41 Pain clinicians do not routinely use pain intensity ratings as part of the pain assessment during clinical practice. Backonja M & Farrar JT. (2015) Are pain ratings irrelevant? Pain Medicine, 16(7): Tide of Thought Shifting Reliance on unidimensional scales to guide treatment have been linked to serious adverse events: Increased incidence of opioid over-sedation from /1,000,000 inpatient hospital days. Documentation of pain is treated as a regulatory nuisance and clinical decision making is not linked to assessment data. Pain is complex and assessment tools need to reflect that complexity, yet be pragmatic in clinical use. Pain assessment is a complex communication process between the patient and clinician. Gordon, DB. Acute pain assessment tools: let us move beyond simple pain ratings. Current Opinion in Anaesthesiology, October 2015, Volume 28 (5),

2 Debate on Self-Report as Gold Standard in Pediatric Pain Intensity Pro: Pain is subjective and can only be assessed via self-report Guides appropriate treatments. Con: Reliance on self-reported pain scores oversimplify the pain experience, Yield only marginal information on which to base clinical decisions, Potentially place children at significant risk for adverse events. Twycross A, Voepel-Lewis T, Vincent C, Franck LS and von Baeyer CL (2015), A debate on the proposition that self-report is the gold standard in assessment of pediatric pain intensity. Clinical Journal of Pain,31(8), Pain Assessment as a Social Transaction Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8); Problem with self-report using a one-dimensional scale Pain is a multi-dimensional complex experience Numeric scale difficult for some to use Requires linguistic and social skills: problematic with some of most vulnerable populations Patients Modulate Pain Reports Pain Assessment as a Social Transaction Beyond the Gold Standard Self-report= gold standard Major disconnect between what is advocated and what clinicians actually do Pain is what the patient says it is acknowledges subjectivity of pain, but ignores complex patient/ clinician relationship Pain as 5 th Vital Sign highlights significance of pain, but can be mechanistic Schiavenato, M & Craig KD. (2010). Pain assessment as a social transaction beyond the Gold Standard. Clinical Journal of Pain, 26(8): Pain Assessment as a Social Transaction Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8); Contributing Factors Experience (Patient Meaning) Expression Biological Sociocultural Developmental/ Psychological Experience/ Empathy Contextual/ Assessment Situational Judgment (Clinician Meaning) Assessment Process Patient Clinician Pain Stimulus Patients modulate pain behaviors and selfreport based on their perception of what s in their best interest Intervention Patient Examples of Contributing Factors in Pain Assessment Biologic Disease, clinical condition, drug influences Clinician Biologic disposition, stress reactivity Sociocultura l Ethnicity, sex, access to healthcare, cultural origin Pt. preferences or biases, age, sex, education, ethnic Developmental Experience/ - Psychological Empathy Age, stress, drug addiction, interpersonal skills, fear Views on pain, trust/ suspicion, Interpersonal skills, critical evaluation of Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8); Previous experience of pain Knowledge, clinical competence, empathy, institutiona l Contextual/ Situational Language, fear/stress, Similarity to clinician, socioeconomic status Workload, interdisciplina ry communication, facility resources

3 Summary of the Social Transaction of Pain Assessment Pain assessment best described as a dynamic process, a transaction: Intersubjective exchange of meaning between patient and clinician Verbal and nonverbal interaction between patient and clinician is modified by the physiologic and social context Process dependent on internal/external factors to both parties and environment News of a New Pain Tool University of Utah 2012 Pilot Project CAPA developed to replace conventional numeric rating scale (NRS; 0-10 scale) Press Ganey scores increased from 18 th to 95 th percentile 55% patients preferred CAPA Nurses preferred CAPA 3:1 over NRS From, Donaldson & Chapman, Clinically Aligned Pain Assessment (CAPA) Pain is More Than Just a Number From, Donaldson & Chapman, Evaluates intensity of pain effect of pain on functionality effect of pain on sleep efficacy of therapy progress toward comfort Engages patient and clinician in a brief conversation about pain resulting in coded evaluation CAPA Tool (modified; original in blue) The conversation leads to documentation- not the other way around. Question Comfort Change in Pain Response Intolerable Tolerable with discomfort Comfortably manageable Negligible pain Getting worse About the same Getting better Pain Control Inadequate pain control Inadequate pain control Partially effective Effective, just about right Fully effective Would like to reduce medication (why?) Functioning Can t do anything because of pain Pain keeps me from doing most of what I need to do Can do most things, but pain gets in the way of some Can do everything I need to Sleep From, Donaldson & Chapman, Awake with pain most of night Awake with occasional pain Normal Sleep Change or Transformation? Change is the fixing of past to future: Better, cheaper, faster, leaner, etc. Transformation is the job of leaders: Building a vision Start with the future and work back Help people fall in love with the future

4 The butterfly is NOT a better, faster caterpillar. Transformation It is a NEW system. Transformation Requirements Supported risk taking Dedicated time Knowledge acquisition and dissemination Leadership s desire for innovation Recognition and reward of efforts Relationships ( From Pesut) Steps of Implementation 1. Define the scope and team 2. Identify and manage the risks 3. Breakdown the work 4. Schedule the work 5. Communicate 6. Measure progress From, Verzuh (2008). University of Minnesota Medical Center A River Runs Through It 1. Defining the scope and team Phase 1 1. Defining the scope and team Phase licensed beds 885 staffed beds Scope (Adult Inpatient) Medical Units Surgical Units Behavioral Units Obstetrics Units Acute Rehabilitation Transitional Care Emergency Departments Perioperative Services Team Champion: Chief Nursing Executive Quality and Performance Improvement Consultants Data Analysts Electronic Health Record Consultant Nurse Managers Staff Nurse Leaders Nurse Educators Communications Department Scope (Adult Outpatient) Infusion Centers Clinics Procedural Areas

5 1. Defining the scope and team Phase 3 Scope (Pediatrics) Process begins with validation of tool in pediatric population 2. Identify and manage the risks Potential failures/risks Failure to gain cooperation of nurses and physicians Concerns of researchers using the numeric scale Failure to increase patient satisfaction or improve pain management Managing Risks Buy-in from key leaders Contacted IRB to notify researchers of change Weekly monitoring of process with monthly monitoring of outcomes 3 & 4. Breakdown and schedule the work Month Aug 13 Sept Oct Nov Dec Jan 14 Feb Mar April May June July Determine & Establish Accountability desired outcomes, Structure /roles at all levels Take to Leadership groups Develop content of presentations Establish plan for data collection Build doc and reports to support Form House wide Group and unit based group Engage Stakeholders Assess current state of practice, research ( Communicate/educate all disciplines Implement: Inpatient Monitor, evaluate, tweak, sustain Implement: Outpatient, 5. Communicate Who Special interest groups: Nurse Managers/Directors, nursing staff, physician groups, APRNs, nursing practice committees, social workers, therapists, champions When Before, frequently throughout What Purpose, expected behaviors, expected outcomes, patient/family feedback, process and outcome measures How Via meetings, newsletters, intranet, patient stories, staff stories, 6. Measure progress Process measures: Weekly compliance report per unit Identification of individuals still using numeric scale: can be coached and counseled Outcome measures: Monthly CAPA outcomes Press Ganey pain satisfaction scores Objective 2: Summarize the outcomes of University of Minnesota Health s implementation of CAPA.

6 Electronic Data Abstraction Process Measures CAPA Compliance Outcome Measures - CAPA Effectiveness of Pain Control (by Month) 30.00% % % 7.50% % January February March April May June July Outcome Measures - CAPA Outcome Measures Press Ganey Quarterly Press Ganey Scores Pre and Post CAPA Implementation 60.00% 57.60% Degree of Comfort by Month Overall Pain Management Staff Did Everything They Could to Help With Pain Pain Well Controlled Capa Beings 12/13 Change in Pain Service 55.20% % % January February March April May June July 50 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15 Q3 15 Q4 15 Overall Pain Management Staff Did Everything Pain Well Controlled

7 Anecdotes Patient perspective: Makes me feel like the nurses care more about my pain. Nurses perspective: It makes sense. Many had been frustrated by numeric scale and liked the change. I hated that 0-10 scale. Nurse Survey 1 med-surg unit (N=21, 67% return) 80% satisfied or very satisfied with implementation 80% felt communication with patients improved with CAPA 71% satisfied with rationale for change 66% preferred CAPA over NRS 47% believe patients have somewhat better pain management with CAPA Thanks to Emily Drobinski, Carrie Hallstrom, Kelly Pavlicek, Mary Sylvestre, Heather White, Clare Zielinski: Unit 8A, UMMC Objective 3 Describe the lessons learned from implementing a complex and culturechanging project. Learnings Numeric scale embedded in many different places in EHR. Pain assessment by many different people Students, faculty, therapists, technicians, etc. Some staff are not skilled at talking with patients; this presented a challenge. Some people resist change! Staff can be the biggest champions! Unexpected Occurrences Information about the CAPA tool Tool not validated according to standards of psychometrics. Study by Drew, Hagstrom & O Connor-Von (unpublished) found no correlation between numerical scores and concurrent CAPA comfort domain. N=30, repeated measures Found that can t compare quantitative data to qualitative data. Donaldson (2014) recommends nonparametric approach in research design

8 Additional Learnings Staff need to recognize this as culture change versus a project Glitches happen in spite of best planning Ripple effects of change occur Barriers along the way: people, processes, tools Facilitators: people, processes, and tools Implications for Outpatient Settings Pain screening question in clinics = numeric intensity score gathered by nonprofessional Didn t cue professional about patient s pain status or concerns (documentation not readily visible) Didn t meet the intent of TJC standard to assess patient s pain in outpatient setting Recommendations for Outpatient Settings Delete numeric pain scale from intake data. Ask screening question: Do you have pain that needs to be addressed at this appointment? Answer flows to Vital Signs flow sheet that is reviewed by RN and provider CAPA available on flow sheet for charting pain assessment Dot phrase available for easy charting in narrative note if preferred by provider. Process Recommendations Make it hard to do the wrong thing, and easy to do the right thing. Joanne Disch, PhD, RN Educate via presentations, electronic learning, written materials, interpersonal meetings. Repeat, repeat again. Utilize electronic medical record to match work flow Other Recommendations Speak to fears and concerns: Fear of making an assessment : some nurses are more comfortable with patient s statement of a number than trying to interpret interaction MDs fear that they won t know how to respond when nurse calls with CAPA information Engage executive leadership as necessary A Tale of Two Emergency Departments

9 West Bank ED 2 nd Quarter East Bank ED 2 nd Quarter Summary 100% 75% 50% 25% 0% 3/25 4/1 4/8 4/15 4/22 4/29 5/6 5/13 5/20 5/27 6/3 6/10 6/17 6/24 Both CAPA and Numeric CAPA Only Numeric Only VP Letter to Staff Pain assessment is not merely the subjective statement of the patient, no more than it is the sole objective decision of the clinician. Rather, pain assessment is the intersubjective exchange of meaning between the patient and clinician. It is a process, which is ongoing and dependent on both the internal and external factors inherent to both the parties and their environment. Summary CAPA is an expanded way to assess pain using a transactional conversation between patient and clinician. Findings: Changing from the numeric scale to the CAPA tool is a cultural change for staff and patients. Patient satisfaction scores improved with concerted effort of staff: Staff did everything to control my pain increased the most and was sustained. Nobody makes a greater mistake than he who did nothing because he could do only a little. Edmund Burke The Impact The Power of Many Drops

10 Questions? References Donaldson, G., & Chapman, C.R. (2013). Pain management is more than just a number. University of Utah Health/ Department of Anesthesiology. Salt Lake City, Utah: Department of Anesthesiology. Schiavenato, M., & Craig, K.D. (2010). Pain assessment as a social transaction: Beyond the gold standard. The Clinical Journal of Pain, 26(8), University of Utah Health Care. (n.d.). Giving patients a voice, not a number. Retrieved from: nursinginnovation/10ideas/two.php Verzuh, E. (2008). Fast forward MBA in project management (3 rd ed.). Hoboken, NJ: John Wiley & Sons, Inc.