NK3 Clinical nurses evaluate and use evidence-based findings in their practice.

Transcription

1 New Knowledge, Innovations, & Improvements EVIDENCE-BASED PRACTICE NK3 Clinical nurses evaluate and use evidence-based findings in their practice. Example A: Provide one example, with supporting evidence, of how clinical nurses used evidence-based findings to implement a practice new to the organization. New Practice Implementation Needed Heather Meece, BSN, RN, CPAN, Nurse Clinician III, a Post Anesthesia Care Unit (PACU) clinical nurse at Advocate BroMenn Medical Center (ABMC) identified that patients who were regularly taking prescribed opioids prior to surgery had very difficult pain control during their PACU stay. These patients frequently had high levels of severe persistent pain and prolonged stays in PACU. Heather brought this problem to the spring 2013 Perianesthesia Shared Governance Committee meeting (Exhibit NK3.A.1 Shared Governance Minutes April 2013). Other committee members from Preadmission Testing (PAT) and Same Day Services (SDS) had similar experiences with patients who had been regularly consuming opioids. These patients seemed to be dissatisfied with their perioperative experience. It was identified that the medical center had no formal way to screen patients at risk for opioid tolerance and there was no specific plan to manage the patients before, during, and after surgery. An interprofessional subgroup of the ABMC Perianesthesia Shared Governance Committee was formed to tackle this problem. Members included: Susan Berry, BSN, RN, Charge Nurse (clinical nurse), Pre-admission Testing Ra Net Bye, BSN, RN, Charge Nurse (clinical nurse), Same Day Services John Jaworowicz, MD, Chief, Section of Anesthesia Shelly Malin, PhD, RN, NEA-BC, Advocate BroMenn Endowed Professor and Mentor Heather Meece, BSN, RN, CPAN, Nurse Clinician III (clinical nurse), PACU Ara Peterson, MSN, RN, Surgical Clinical RN Reviewer and Mentor, Quality Resource Management Yvonne Rees, RN, CGRN, Nurse Clinician III (clinical nurse), Same Day Surgery and Perianesthesia Shared Governance Chair Sonia Vercler, RN, CGRN, Perianesthesia Nurse Manager (at the time) Evidence-Based Findings Utilized The Shared Governance subgroup conducted a literature review using key words: opioid tolerance, pain management, postoperative, perioperative care, and chronic pain. The subgroup narrowed the articles down to 15 and reviewed key findings. The literature was clear that patients being prescribed opioids for chronic pain were NK3 ExA Advocate BroMenn Medical Center 1

2 increasing and that treating these patients with acute surgical pain was difficult for practitioners (Dykstra, 2012; Mitra, 2004). In the literature experts such as Anesthesiologists, Certified Nurse Specialist of Pain Management and Anesthesiology Educators outlined perioperative intervention recommendations for this subgroup of patients (D Arcy, 2010; Dykstra, 2012; Mitra, 2004; Richebe, 2009; Rozen & Grass, 2005). Appropriate interventions for pre-, intra-, and post-operative care were suggested but lacked baseline data to illustrate their benefit. The subgroup decided to pursue developing their own evidence-based plan of care for opioid tolerant patients. Although all patients with opioid tolerance may have difficulty with acute pain control, the subgroup decided to focus on spine surgery patients. Their perception was that this select group dealt with chronic pain and, therefore, had the highest incidence of opioid tolerance and poor pain control perioperatively. The Iowa Model of Evidence-Based Practice was used to take a systematic approach in addressing this issue (Exhibit NK3.A.2 Iowa Model: Opioid Tolerance). By the fall of 2013, the following PICO question was developed: Does an evidence-based pain management plan of care for patients at risk for opioid tolerance undergoing spine surgery positively influence their perioperative experience as compared to current practice? The goals of the project were: 1. Patients report/exhibit minimal/moderate pain perioperatively as evidenced by reported pain scores utilizing the 0-10 numeric pain intensity scale. 2. Patient s length of stay is less than 60 minutes Phase 1 Recovery (PACU). 3. Patients report satisfaction related to perioperative pain control as good or very good. 4. Patients planned for home discharge from Phase 2 recovery are discharged to home and not admitted to a nursing unit for postoperative pain management. Clinical Nurses Use Evidence to Implement a New Practice The subgroup obtained baseline data prior to creating a pain management plan of care. Baseline data reflected current practices and their outcomes, and provided evidence of how well the plan of care developed by the subgroup worked. A prospective data collection tool was developed by the subgroup members (Exhibit NK3.A.3 Data Collection Tool). A screening tool to help the PAT nurses identify patients meeting inclusion criteria for the study was also developed. NK3 ExA Advocate BroMenn Medical Center 2

3 The subgroup used the literature to help define which spine surgery patients would be at greatest risk for opioid tolerance. Tolerance was defined as needing more of a substance to get the same effect (Richebe, 2009). Questioning patients regarding whether they were using more pain medication to achieve desired pain relief did not seem to be a reliable way to assess risk for tolerance. The subgroup wanted a concise sensitive indicator, so they developed an operational definition for patients at risk for opioid tolerance as regularly consuming prescribed opioid medications daily for greater than or equal to one week based on information from two sources (Carroll, Angst, & Clark, 2004; Swensen, 2005). An acronym for Positive Opioid Risk Assessment or PORA was developed to easily identify these patients. Baseline data were collected from December 2013 to February Nurses from PAT, SDS, and PACU were responsible for collecting the data pertaining to their area. Ra Net, SDS, and Heather, PACU, completed patient satisfaction questionnaires with patients on postoperative day one. Patients were surveyed on their satisfaction with the information they received prior to surgery from both the PAT nurse and the SDS nurse regarding the pain management plan. They were also surveyed on their satisfaction with the nurses concern for patients comfort and how well pain was controlled perioperatively. Patients rated their satisfaction utilizing a 1-4 scale with 1 being very poor and 4 being very good. Twenty-nine patients, with completed tools and questionnaires, were included in the baseline data. Baseline Data Results: Metric Results Average PACU length of stay in minutes 90 PACU Patient Satisfaction: Good or Very Good 79.31% Post op Pain Scores SDS PACU Arrival Pain Score > or = to 5 48% 69% 69% Unplanned Admission 0 PACU Discharge Baseline data results of patients at risk for opioid tolerance demonstrated that the most significant need for pain score improvement was in PACU where 69% of patients scored their pain as greater than or equal to five on arrival and continued in this range at discharge. Another finding was that 83% of patients had PACU length of stays that were greater than 60 minutes and averaged 90 minutes. Most patients rated their satisfaction with pain control as good or very good, but five patients rated their pain control in PACU as poor or very poor. No patients were admitted to the medical center for pain control. These results verified the need for interventions to improve the NK3 ExA Advocate BroMenn Medical Center 3

4 experience of the patients at risk for opioid tolerance and served as a baseline for comparison. The Shared Governance subgroup spent the next year working on development of evidence-based plan of care for patients at risk for opioid tolerance undergoing spine surgery (Exhibit NK3.A.2 Iowa Model: Opioid Tolerance). Interventions were derived by the subgroup nurses from the literature reviewed and with input from Dr. Jaworowicz. The plan of care consisted of evidence-based interventions for the nurses and anesthesia providers during each perioperative phase. In addition to the subgroup members listed above, the following individuals were also involved with its approval and development: Steve Pinneke, MS, PharmD, BCPS, Pharmacy Services Director Sandy Young, RN, Clinical Informaticist Logan Frederick, RHIA, BS, Operations Improvement Leader Colleen Ewen, MBA, BSN, RN, Clinical Development Specialist Lori Harper, MBA, MSN, RN, NE-BC, Director of Nursing Practice Pharmacy Clinical Informatics Operational Improvement Clinical Education Clinical Administration Approval of medication orders Development of electronic nursing documentation and anesthesia computerized order entry order sets Algorithm development Approval of anesthesia order set formatting and Pain and Opioid Fact Sheet development Approval of nursing intervention and documentation Once the plan of care was finalized approvals were sought from pharmacy and nursing. A Nursing Documentation Checklist was developed to show that PORA Plan of Care interventions had been completed at every perioperative phase. Screening questions were added to the electronic medical record. A patient education tool Opioid Fact Sheet was developed to help educate the patient about prescription opioid use and how ABMC would be partnering with them to manage their pain prior to, during and after surgery. At the May 4, 2015, Perianesthesia department meeting all PAT, SDS, and PACU nurses were educated on screening patients for PORA, the PORA Plan of Care, and the nursing documentation checklist (Exhibit NK3.A.4 Nursing Documentation Checklist). A quiz following this education demonstrating understanding was also completed. An algorithm was used as a quick visual reference tool for associates (Exhibit NK3.A.5 Opioid Tolerance Algorithm). The algorithm was posted at nurses stations, associate NK3 ExA Advocate BroMenn Medical Center 4

5 notification boards, and was placed on all PORA positive patient charts. Anesthesiology associates including Certified Registered Nurse Anesthetists (CRNAs) received a detailed and in-person communication from Ra Net and Heather. Ra Net and Heather also showed the care plan and algorithm to neurosurgeons Emilio Nardone, MD; Ann Stoink, MD, and Jason Seibly, DO, as well as sent a detailed to all neurosurgeons and their residents. A detailed regarding implementation was sent to Trayce Bartley, MSN, RN, Director of Perioperative Services; Kristin Peterson, MSN, RN, Nurse Manager, Progressive Care Unit; and the Neurosurgery Operating Room (OR) Circulators. Information regarding the project and opportunities for questions were allotted at unit huddles. The PORA Plan of Care went into effect May 18, Post-implementation data collection began with patients scheduled for surgery September 1, 2015 through November 10, The same prospective process was followed as for baseline data collection. Seventeen tools and patient satisfaction questionnaires were completed. Fewer spine surgery patients screened positive during the post-implementation data collection period. This was attributed to two factors, including a legislative change in the prescription requirements for schedule II narcotics and increased awareness by the neurosurgeons at the medical center regarding the effects of opioid tolerance on postoperative pain management. Fewer patients were prescribed opioids during the weeks prior to surgery. The subgroup agreed that a retrospective audit of at least 15 patients that screened positive from the time of implementation on May 18, 2015 was needed to gain a larger analysis group. Fifteen additional records were audited but were not questioned on patient satisfaction based on the lapse in time from their experience. In reviewing the post-implementation data of 32 patients who screened positive for PORA revealed: Twenty-one patients screened positive and received the full plan of care, including the PORA preoperative medications Eleven patients screened positive but did not receive the full plan of care as the PORA preoperative medications were omitted Post-implementation data analysis showed that an evidence-based pain management plan of care for patients at risk for opioid tolerance undergoing spine surgery positively influenced their perioperative experience as compared to prior practices. All post-implementation patients (100%) rated pain control as good or very good as compared to baseline of 79.3%. PACU length of stay decreased by an average of 23 minutes. Patients who received PORA preoperative medications had lower pain scores by discharge from PACU in comparison to their preoperative pain score. Patients who did not receive preoperative medication had higher pain scores by discharge from PACU in comparison by a mean difference of NK3 ExA Advocate BroMenn Medical Center 5

6 Data results demonstrated that the most influential piece of the PORA Plan of Care was the importance of receiving the preoperative medications. Patients that received the full plan of care including preoperative medications Gabapentin 600mg orally, Acetaminophen 1000mg orally, and Metoclopramide10mg intravenously had the most significant improvements. The severity of their pain was less, especially at discharge from PACU. Patients who received these preoperative medications had an average PACU length of stay of 66 minutes as compared to the baseline group of 90 minutes. Post-implementation data was shared by Ra Net at the December 14, 2015 Anesthesia Section meeting. The anesthesiologists present were impressed with the data. Ra Net shared the finding that there were 11 patients that screened positive for PORA that did not receive the full plan of care due to the omission of the preoperative medications. Demonstrating the impact of the preoperative medications was valuable in ensuring anesthesia buy-in to the importance of utilizing the full plan of care. Dr. Jaworowicz expressed his desire to expand PORA screening and plan of care to all non-emergent surgical patients to enhance their perioperative experience as well. This was accomplished April 18, References Bourne, N. (2008). Managing acute pain in opioid tolerant patients. Journal of Perioperative Practice, 18(11), Carroll, I., Angst, M., & Clark, J. D. (2004). Management of perioperative pain in patients chronically consuming opioids. Regional Anesthesia and Pain Medicine, 29(6), D Arcy, Y. (2010). Managing chronic pain in acute care, getting it right. Nursing, 40(4), Dumas, E., & Pollack, G. (2008). Opioid tolerance development: A pharmacokinetic/pharmacodynamic perspective. American Association of Pharmaceutical Scientists, 10(4) Dykstra, K. (2012). Postoperative pain management in the opioid-tolerant patient with chronic pain: An Evidence-based practice project. Journal of PeriAnesthesia Nursing, 27(6), Jarzyna, D. (2005). Opioid tolerance: A perioperative nursing challenge. MedSurg Nursing, 14(6), Khan, Z. H., Rahim, M., Makarem, J., Khan, R. H. (2011). Optimal dose of Preincision/post-incision gabapentin for pain relief following lumbar laminectomy: a randomized study. Acta Anaesthesiologica Scandinavica 55(3), doi: /j x NK3 ExA Advocate BroMenn Medical Center 6

7 Mancini, R., & Filicetti, M. (2010). Pain management of opioid-tolerant patients undergoing surgery. American Journal of Health-System Pharmacy, 67(11), p. doi: /ajhp Mitra, S., & Sinatra, R. (2004). Perioperative management of acute pain in the opioiddependent patient. Anesthesiology, 101(1), Noe, C., & MD, Williams, C. (2012). The Benefits of interdisciplinary pain management. Journal of Family Practice, 61(4), Pasero, C. (2013). Ketamine for refractory pain. Medscape. Richebe, P., & Beaulieu, P. (2009). Perioperative pain management in the patient treated with opioids: Continuing professional development. Canadian Journal of Anesthesia, 56, Rozen, D., & Grass, G. (2005). Perioperative and intraoperative pain and anesthetic care of chronic pain and cancer pain. World Institute of Pain, 5(1), Swenson, J., Davis, J., & Johnson, B. (2005). Perioperative Care of the Chronic Opioid- Consuming Patients. Anesthesiology Clinic of North America, 23(2005), Vaghari, B., Baratta, J. L., Gandhi, K. (2013). Perioperative Approach to Patients with Opioid Abuse and Tolerance. Anesthesiology News jlm NK3 ExA Advocate BroMenn Medical Center 7

8 Exhibit NK3.A.1 Advocate BroMenn Medical Center Shared Governance 4/22/13 Agenda 1430 Hand-off Tool-Sonia Opioid Tolerance Pain Project-Heather AIDET competencies- SDS to OR Open Discussion

9 Perianesthesia Shared Governance Minutes 4/22/ Attendees: Sonia Vercler; Ra Net Bye; Ben Watkins; Corinn Desmond; Heather Meece; Yvonne Rees Hand-off Tool- Discussion regarding whether to require documentation or use the sheet as a prompt in reporting Opioid Tolerance Pain Project- Heather dispersed articles for us to read; documented who has which article; Will report on findings in two weeks-may See attached Evidence Matrix Worksheet. AIDET competencies-discussion regarding use during hand-off to OR; use key words and behaviors Patient Satisfaction-Ben shared the last quarter mean score that showed a steady improvement over the year; patients #1 concern is information regarding delays; discussion regarding statistics and suggestions for improvement; See attached reports Miscellaneous-Waiting area Volunteers would like us to instruct the family to check in with the volunteers before going to eat, etc. Corinn will write script for including asking patient to fill out survey. Ra Net attended the EBP conference and reported that currently other facilities are using the Iowa Model EBP format to improve outcomes

10 Exhibit NK3.A.2 Advocate BroMenn Medical Center Problem-Focused Triggers IOWA MODEL OF EVIDENCE-BASED PRACTICE TO PROMOTE QUALITY CARE Identification of clinical problem Problem Statement/Problem Identified: It is difficult to control postoperative pain in opioid tolerant patients having surgery as evidenced by: Patient reports/exhibits severe (intolerable) pain postoperatively Patients have a prolonged length of stay in Phase 1 or Phase 2 Recovery Patients are admitted to a nursing unit instead of being discharged to home for pain management PICO Question (P) (I) (C) (O) Population: opioid tolerant patients undergoing back/spine surgery Intervention: use of an evidence-based perioperative pain management plan of care Comparison: current perioperative plan of care Outcome(s): satisfactory perioperative pain management as evidenced by: 11/22/13 (final) Patient reports/exhibits minimal/moderate (tolerable) pain perioperative as evidenced by reported pain scores utilizing the 0-10 numeric pain intensity scale. Patients have a length of stay < 60 minutes in Phase 1 Recovery (PACU). Patients planned for home discharge from Phase 2 recovery are discharge to home and not admitted to a nursing unit for postoperative pain management Patients report satisfaction related to perioperative pain control as good or very good

11 ASSEMBLE RELEVANT RESEARCH AND RELATED LITERATURE Literature Review Critique and synthesize research for use in practice Key words: opioid tolerance, pain management, postoperative, perioperative, chronic pain and surgery Literature review results: Number of articles = 15 Reference List: attached Key findings /over view: attached Level of evidence: attached Critical literature review :attached Synthesis of literature review findings: attached 11/22/13

12 PILOT THE CHANGE IN PRACTICE Select outcomes to be achieved Collect baseline data Patient reports/exhibits minimal/moderate (tolerable) pain perioperatively Patients have a length of stay < 60 minutes in Phase 1 Recovery Patients planned for home discharge from Phase 2 recovery are discharge to home and not admitted to a nursing unit for postoperative pain management Patients report satisfaction related to perioperative pain control as good or very good Identification of pilot patient population (inclusion criteria) to evaluate: Inclusion Criteria attached Data collection document Template: attached Data collection form: attached Data collection Method(s): Prospective & Retrospective Timeline: December, 2013-January, 2014 Pilot data collection: 4 patients (November, 2013) Cases scheduled beginning December 2, 2013: Data Collection: December, 2013 & January, 2014 Cases scheduled beginning:? Data collection process plan: attached Findings: Analyze findings: Present baseline data collection analysis: 11/22/13 (final)

13 DESIGN EVIDENCE-BASED GUIDELINES Perioperative Pain Management Plan of Care For Opioid Tolerant Patients Undergoing Surgery Overview (abstract) Abstract An 8 member Subgroup of a Peri-operative Shared Governance group was assigned the task of developing an EBP project related to pain. A problem was identified that patients who had been taking opioids prior to surgery were difficult to manage post op in Phase I recovery. They frequently had high levels of severe persistent pain and prolonged PACU stays. They seemed to be dissatisfied overall with their peri-op experience and had complicated phase II stays which resulted in unplanned admissions. From the beginning, it was clear that there was no formal way to identify patients at risk for opioid tolerance. There also was no specific plan to manage the patient prior to, during, and after surgery. A Literature review using key words: opioid tolerance, pain management, postoperative, perioperative, chronic pain and surgery were conducted. The group narrowed the articles down to 13 and reviewed the key findings. The literature was clear that patients being prescribed opioids for chronic pain were on the rise and that treating these patients for acute pain was difficult for practitioners. A couple institutions had developed plans of care for this subgroup of patients with some success. There were also several care plans developed by experts lined out in tables for pre, intra, and post op care. The group decided to pursue developing their own evidence based plan of care to help manage the opioid tolerant patient in their institution. The chief Anesthesiologist for the hospital was consulted and agreed to work with the group on developing a multidisciplinary plan of care. Baseline data was needed to prove the perceptions of the staff to be true. The group decided to narrow the patient population to patients having back/spine surgery and who have been taking prescribed opioids for greater than a week. Since we wanted to see what the patient s satisfaction was it was decided to do prospective data collection with some patient satisfaction questions being asked along with objective data being collected. The objective data includes the patient reporting that they were instructed to and take their own pain medication the day of surgery, treatments pre-op for pain and pain management education, intra-op narcotic use by Anesthesia, post-op narcotic use, and pain scores in the PACU. Patient satisfaction questions included the patient rating the information they received regarding pain management prior to the surgery by both the pre-testing nurse and the pre-op nurse. The patient was also asked to rate the concerns for comfort and how well pain was controlled pre-op and post-op. Length of stay in the PACU is measured and the number of unplanned admissions was to be calculated. A Baseline Data tool and process for collection was devised and trialed for a month. After a month changes to the process for data collection were made to get better compliance with tool completion. It was identified that a significant number of patients should meet inclusion and that a plan of care for these patients was worthy at the group s institution. Baseline data collection is ongoing at this time. The baseline data will be analyzed and the project revised as necessary. The group will work on developing a plan of care or care path for patients at risk for opioid tolerance based on

14 the literature and data collected. The efficacy of the care plan will be evaluated at the completion of staff education and implementation. Identify Key Stakeholders Opioid Tolerance and Pain Management in the Perioperative Setting Key Stakeholder List Patients Anesthesia Providers Neurosurgery Attending and Resident Physicians OR Director and Leadership Team Perioperative Nursing Staff Nursing Leadership IT staff Pharmacy Approvals Needed see process improvement detailed plan Education Staff Pain Education-Power Point and Competency Quiz with 100% completion (see attached) Medical Staff education-poster information Department of Anesthesia Neurosurgery (Attending and Residents) Surgery Section Chiefs

15 Care Path Development with Supporting Literature Evidence Based Practice Positive Opioid Risk Assessment (PORA) Plan of Care Preadmission Testing (PAT) Nurse Identify Adult Patients scheduled for a non-emergent Spine Surgery Screen for Opioid use and tolerance risk ref. 1, 2, 3, 4, 5, 8, 11, 12 Does the patient take prescribed home opioid pain medication daily? Has the patient taken prescribed home opioid pain medication on a daily basis for seven days or more? ref. 3, 12, 14 If yes to both questions then patient is considered at risk for opioid tolerance and placed on care plan. Communicating Positive Opioid Tolerance Risk Assessment (PORA) PORA sticker placed on front of chart. PORA is added to the patient specific comments on surgery schedule. PORA algorithm placed in chart. Recommend Anesthesia evaluation during PAT visit or chart review Patient education Continue pain medication, patches, or Opioid agonist (Methadone) regimen morning of surgery Pain and Opioid fact sheet (see attached) Anesthesiologist: Validate Opioid Tolerance Risk Assessment Make a pain management plan with the patient. ref. 1, 2, 3, 4, 5, 8, 11, 12 Consider Pain Consult ref. 1, 2, 8,

16 Same Day Surgery (SDS) Nurse Ensure usual opioid pain medication regimen is continued day of surgery to prevent withdrawal and to maintain opioid requirements ref.1, 2, 4, 5, 7, 8, 11, 12, 14 Administer pre anesthesia medications as ordered Document pain score and pain goal ref. 7, 11 Assess, treat, and reassess pain scores Consider non pharmacological pain management strategies: Positioning, blankets, ice ref. 1, 11, 13 Anesthesiologist Utilize Anesthesia Preop PORA Order Set Acetaminophen 1000mg PO/IV x 1 Pre-op ref. 2, 8, 9, 11 Gabapentin 600mg PO x 1 Pre-op (if did not already take Lyrica or Gabapentin at home am of surgery) ref. 9, 11, 14, 15 Metoclopramide 10mg IV x 1 Pre-op ref. 8 Other recommended medication orders from usual Anesthesia Preop order set based on level of pain or anxiety: Intra-operative Sublimaze 50mcg-100mcg IV PRN, or Hydromorphone 0.5-1mg IV PRN x 1 Pre-op PRN ref. 2, 7, 9, 11, 12 Methadone 5-10mg PO/IV ref. 2, 14 Midazolam 2m IV PRN for anxiety ref. 1,2 Anesthesiologist/Nurse Anesthetist (CRNA) Increase opioid by 2-4 times an Opioid naïve, or by 25-50% ref. 1, 4, 7, 9, 11, 12, 14 Multimodal analgesia: Acetaminophen/Ketorolac as appropriate ref. 1, 2, 4, 7, 9, 12, 11 Avoid Naloxone ref. 8,9

17 Post Anesthesia Care Unit (PACU) Nurse Assess, treat and reassess pain using increased opioid dose guidelines and multimodal medications ref. 1, 2, 7, 8, 9, 12 Goal to achieve pain goal or pain score less than 5 Use of non-pharmacologic techniques: Ice, Heat, Positioning ref. 1, 11, 13 Closely monitor respirations, oxygen saturation, and consider capnography ref. 12 Anesthesiologist/CRNA : Utilize Anesthesia Postop PORA Order Set: Hydromorphone 0.5-1mg IV Q 10 min prn with a max PACU dose of 4mg Sublimaze 25mcg-50mcg IV Q 5 min prn with a max PACU dose of 400mcg Morphine 2mg-5mg IV Q 5min with a max PACU dose of 20m Use of opioids postoperatively to treat pain at increased doses or 25-50% above baseline ref. 4, 7, 9, 11, 12 Reference List 1Mitra, S., & Sinatra, R. (2004). Perioperative management of acute pain in the opioiddependent patient. Anesthesiology, 101(1), Dykstra, K. (2012). Postoperative pain management in the opioid-tolerant patient with chronic pain: An Evidence-based practice project. Journal of PeriAnesthesia Nursing, 27(6), Swenson, J., Davis, J., & Johnson, B. (2005). Perioperative Care of the Chronic Opioid-Consuming Patients. Anesthesiology Clinic of North America, 23(2005), Bourne, N. (2008). Managing acute pain in opioid tolerant patients. Journal of Perioperative Practice, 18(11), Mancini, R., & Filicetti, M. (2010). Pain management of opioid-tolerant patients undergoing surgery. American Journal of Health-System Pharmacy, 67(11), p. doi: /ajhp090408

18 6Dumas, E., & Pollack, G. (2008). Opioid tolerance development: A pharmaokenetic/pharmacodynamic perspective. American Association of Pharmaceutical Scientists, 10(4) D Arcy, Y. (2010). Managing chronic pain in acute care, getting it right. Nursing, 40(4), Rozen, D., & Grass, G. (2005). Perioperative and intraoperative pain and anesthetic care of chronic pain and cancer pain. World Institute of Pain, 5(1), Richebe, P., & Beaulieu, P. (2009). Perioperative pain management in the patient treated with opioids: Continuing professional development. Canadian Journal of Anesthesia, 56, Noe, C., & MD, Williams, C. (2012). The Benefits of interdisciplinary pain management. Journal of Family Practice, 61(4), Jarzyna, D. (2005). Opioid tolerance: A perioperative nursing challenge. MedSurg Nursing, 14(6), Carroll, I., Angst, M., & Clark, J. D. (2004). Management of perioperative pain in patients chronically consuming opioids. Regional Anesthesia and Pain Medicine, 29(6), Pasero, C. (2013). Ketamine for refractory pain. Medscape. 14 Vaghari, B., Baratta, J. L., Gandhi, K. (2013). Perioperative Approach to Patients with Opioid Abuse and Tolerance. Anesthesiology News. Benjamin Vaghari,MD, Jaime L. Baratta, MD, Kishor Gandhi MD, MPH, CPE, (2013) Perioperative Approach to Patients with Opioid Abuse and Tolerance Anesthesiology News June Khan, Z. H., Rahim, M., Makarem, J., Khan, R. H. (2011). Optimal dose of Preincision/post-incision gabapentin for pain relief following lumbar laminectomy: a randomized study. Acta Anaesthesiologica Scandinavica 55(3), doi: /j x

19 IMPLEMENT EBP ON PILOT UNIT Process Improvement Detailed Plan Action Step Target Dates Who is Responsible Completed Comments Develop Care Path ALL 10/17/14 Create Document Checklist/screening tool April 2015 Ra Net Bye Heather Meece 4/15/15 Request for IS to make online version, will stay as paper until post implementation data can show an Anesthesia Order Set Committee members DR. Jaworowicz Steve Peneke Create Pt. Ed tool 4/15/15 Colleen Ewen 5/15/15 improvement 10/17/14 Online version completed 4/1/15 Get all approvals February Ra Net and Heather Meece Design Education Roll-out 4/10 Power Point complete May staff meeting conduct ed. Ra Net Bye Heather Meece 2/1/15 See key stakeholder list Power point 4/10/15 Staff Ed 5/4/15 All members of the Anesthesia staff and Surgical Neuro nurses received detailed Inform and Educate key stakeholders Implement New Care Path (30 days) Data Collection with new process April/May 2015 Ra Net Bye Heather Meece Prior to go-live May 18, 2015 ALL 5/18/15 September 1, days Ra Net Bye & Heather Meece Analysis of Data October 2015 Logan Fredrick Ra Net Bye & Heather Meece 10/30/15 /meetings/one on one 11/19/15 Results discussed with Shelly Malin/Logan Fredrick

20 EVALUATE PROCESS CHANGE AND OUTCOME(S) Post Implementation Data Collection Process Repeat Data Collection Process and goals as utilized for baseline data: Start with patients charts created in PAT on September 1, Collect for a total of 30 days or 30 patients. Patients having surgery will be screened by staff from PAT for inclusion criteria (attached). If patients meet the inclusion criteria, a data collection tool will be placed on the chart. Associates in each department will be responsible for filling in information as directed by the tool. All forms will be pulled from the chart in recovery and placed in a purple binder. Heather or Ra Net will collect forms and make a plan for interviewing patients the day after their procedure. Missing information will also be completed as able from the medical record. Completed forms will be placed in Ra Net s mailbox in the staff lounge. Heather and Ra Net will collected completed forms and enter data in an Excel spreadsheet. Data will be evaluated early in October and a decision on whether or not to extend the collection time period will be made. Staff education on the data collection process will be provided by Ra Net for SDS and PACU, and Sue for PAT in August. Education will be done during the daily staff huddle and will include the data collection plan and instructions for use of the data collection tool. Ra Net and Heather will predetermine patients having back/spine surgery through the use of the preoperative schedule. They will retrospectively compile a list of patients meeting inclusion criteria. This evaluation will test the application of inclusion /exclusion criteria by the Preadmission Testing staff. The data collection plan was reviewed and approved by the Chair of Anesthesia. After evaluating # of patients meeting inclusion may extend timeline to include at least 30 patients. MODIFY THE PRACTICE GUIDELINE(S) INSTITUTE THE CHANGE IN PRACTICE MONITOR AND ANALYZE STRUCTURE, PROCESS, AND OUTCOME DATA

21 Exhibit NK3.A.3 Advocate BroMenn Medical Center PRE-ADMISSION TESTING Place an X next to the patient's planned surgical procedure X Anterior Cervical Disc Fusion DLL w/instrumentation Lumbar Fusion Laminectomy Kyphoplasty Microdiscectomy PRE-ADMISSION TESTING Place an X next to the patient's prescribed home opioid pain medication(s) X X X X Actiq Fentora Oramorph SR Stadol Anexsia Fentanyl Patch Oxycotin Statex Astromorph PF Infumorph OxyFast Subutex Avinza Kadian OxyIR Sumlimaze Buprenex Lorcet Panacet Supeudol Codeine Lortab Percocet Talwin Co-Gesic M.O.S. RMS Uniserts Talwin NX Demerol M.O.S.-SR Roxanol Tylenol /codeine DepoDur M-Eslon Roxicet Tylox Dilaudid Morphine H.P. Roxicodone Ultram Dilaudid-HP M-Oxy Roxilox Ultram ER Dolora MS Contin Ryzolt Vicodin Duramorph PF MSIR Zydone Durgesic Norco Endocet Nucynta ETH-Oxydose PRE-ADMISSION TESTING Indicate patient's home opioid use Does the patient take prescribed home opioid pain medication daily? Yes No Has the patient taken prescribed home opioid pain medication Yes No for 7 days or more? * If both answers above are reported as "YES", please include the data collection tool in the patient's chart. PATIENT STICKER Comments:

22 Exhibit NK3.A.2 Advocate BroMenn Medical Center Problem-Focused Triggers IOWA MODEL OF EVIDENCE-BASED PRACTICE TO PROMOTE QUALITY CARE Identification of clinical problem Problem Statement/Problem Identified: It is difficult to control postoperative pain in opioid tolerant patients having surgery as evidenced by: Patient reports/exhibits severe (intolerable) pain postoperatively Patients have a prolonged length of stay in Phase 1 or Phase 2 Recovery Patients are admitted to a nursing unit instead of being discharged to home for pain management PICO Question (P) (I) (C) (O) Population: opioid tolerant patients undergoing back/spine surgery Intervention: use of an evidence-based perioperative pain management plan of care Comparison: current perioperative plan of care Outcome(s): satisfactory perioperative pain management as evidenced by: 11/22/13 (final) Patient reports/exhibits minimal/moderate (tolerable) pain perioperative as evidenced by reported pain scores utilizing the 0-10 numeric pain intensity scale. Patients have a length of stay < 60 minutes in Phase 1 Recovery (PACU). Patients planned for home discharge from Phase 2 recovery are discharge to home and not admitted to a nursing unit for postoperative pain management Patients report satisfaction related to perioperative pain control as good or very good

23 ASSEMBLE RELEVANT RESEARCH AND RELATED LITERATURE Literature Review Critique and synthesize research for use in practice Key words: opioid tolerance, pain management, postoperative, perioperative, chronic pain and surgery Literature review results: Number of articles = 15 Reference List: attached Key findings /over view: attached Level of evidence: attached Critical literature review :attached Synthesis of literature review findings: attached 11/22/13

24 PILOT THE CHANGE IN PRACTICE Select outcomes to be achieved Collect baseline data Patient reports/exhibits minimal/moderate (tolerable) pain perioperatively Patients have a length of stay < 60 minutes in Phase 1 Recovery Patients planned for home discharge from Phase 2 recovery are discharge to home and not admitted to a nursing unit for postoperative pain management Patients report satisfaction related to perioperative pain control as good or very good Identification of pilot patient population (inclusion criteria) to evaluate: Inclusion Criteria attached Data collection document Template: attached Data collection form: attached Data collection Method(s): Prospective & Retrospective Timeline: December, 2013-January, 2014 Pilot data collection: 4 patients (November, 2013) Cases scheduled beginning December 2, 2013: Data Collection: December, 2013 & January, 2014 Cases scheduled beginning:? Data collection process plan: attached Findings: Analyze findings: Present baseline data collection analysis: 11/22/13 (final)

25 DESIGN EVIDENCE-BASED GUIDELINES Perioperative Pain Management Plan of Care For Opioid Tolerant Patients Undergoing Surgery Overview (abstract) Abstract An 8 member Subgroup of a Peri-operative Shared Governance group was assigned the task of developing an EBP project related to pain. A problem was identified that patients who had been taking opioids prior to surgery were difficult to manage post op in Phase I recovery. They frequently had high levels of severe persistent pain and prolonged PACU stays. They seemed to be dissatisfied overall with their peri-op experience and had complicated phase II stays which resulted in unplanned admissions. From the beginning, it was clear that there was no formal way to identify patients at risk for opioid tolerance. There also was no specific plan to manage the patient prior to, during, and after surgery. A Literature review using key words: opioid tolerance, pain management, postoperative, perioperative, chronic pain and surgery were conducted. The group narrowed the articles down to 13 and reviewed the key findings. The literature was clear that patients being prescribed opioids for chronic pain were on the rise and that treating these patients for acute pain was difficult for practitioners. A couple institutions had developed plans of care for this subgroup of patients with some success. There were also several care plans developed by experts lined out in tables for pre, intra, and post op care. The group decided to pursue developing their own evidence based plan of care to help manage the opioid tolerant patient in their institution. The chief Anesthesiologist for the hospital was consulted and agreed to work with the group on developing a multidisciplinary plan of care. Baseline data was needed to prove the perceptions of the staff to be true. The group decided to narrow the patient population to patients having back/spine surgery and who have been taking prescribed opioids for greater than a week. Since we wanted to see what the patient s satisfaction was it was decided to do prospective data collection with some patient satisfaction questions being asked along with objective data being collected. The objective data includes the patient reporting that they were instructed to and take their own pain medication the day of surgery, treatments pre-op for pain and pain management education, intra-op narcotic use by Anesthesia, post-op narcotic use, and pain scores in the PACU. Patient satisfaction questions included the patient rating the information they received regarding pain management prior to the surgery by both the pre-testing nurse and the pre-op nurse. The patient was also asked to rate the concerns for comfort and how well pain was controlled pre-op and post-op. Length of stay in the PACU is measured and the number of unplanned admissions was to be calculated. A Baseline Data tool and process for collection was devised and trialed for a month. After a month changes to the process for data collection were made to get better compliance with tool completion. It was identified that a significant number of patients should meet inclusion and that a plan of care for these patients was worthy at the group s institution. Baseline data collection is ongoing at this time. The baseline data will be analyzed and the project revised as necessary. The group will work on developing a plan of care or care path for patients at risk for opioid tolerance based on

26 the literature and data collected. The efficacy of the care plan will be evaluated at the completion of staff education and implementation. Identify Key Stakeholders Opioid Tolerance and Pain Management in the Perioperative Setting Key Stakeholder List Patients Anesthesia Providers Neurosurgery Attending and Resident Physicians OR Director and Leadership Team Perioperative Nursing Staff Nursing Leadership IT staff Pharmacy Approvals Needed see process improvement detailed plan Education Staff Pain Education-Power Point and Competency Quiz with 100% completion (see attached) Medical Staff education-poster information Department of Anesthesia Neurosurgery (Attending and Residents) Surgery Section Chiefs

27 Care Path Development with Supporting Literature Evidence Based Practice Positive Opioid Risk Assessment (PORA) Plan of Care Preadmission Testing (PAT) Nurse Identify Adult Patients scheduled for a non-emergent Spine Surgery Screen for Opioid use and tolerance risk ref. 1, 2, 3, 4, 5, 8, 11, 12 Does the patient take prescribed home opioid pain medication daily? Has the patient taken prescribed home opioid pain medication on a daily basis for seven days or more? ref. 3, 12, 14 If yes to both questions then patient is considered at risk for opioid tolerance and placed on care plan. Communicating Positive Opioid Tolerance Risk Assessment (PORA) PORA sticker placed on front of chart. PORA is added to the patient specific comments on surgery schedule. PORA algorithm placed in chart. Recommend Anesthesia evaluation during PAT visit or chart review Patient education Continue pain medication, patches, or Opioid agonist (Methadone) regimen morning of surgery Pain and Opioid fact sheet (see attached) Anesthesiologist: Validate Opioid Tolerance Risk Assessment Make a pain management plan with the patient. ref. 1, 2, 3, 4, 5, 8, 11, 12 Consider Pain Consult ref. 1, 2, 8,

28 Same Day Surgery (SDS) Nurse Ensure usual opioid pain medication regimen is continued day of surgery to prevent withdrawal and to maintain opioid requirements ref.1, 2, 4, 5, 7, 8, 11, 12, 14 Administer pre anesthesia medications as ordered Document pain score and pain goal ref. 7, 11 Assess, treat, and reassess pain scores Consider non pharmacological pain management strategies: Positioning, blankets, ice ref. 1, 11, 13 Anesthesiologist Utilize Anesthesia Preop PORA Order Set Acetaminophen 1000mg PO/IV x 1 Pre-op ref. 2, 8, 9, 11 Gabapentin 600mg PO x 1 Pre-op (if did not already take Lyrica or Gabapentin at home am of surgery) ref. 9, 11, 14, 15 Metoclopramide 10mg IV x 1 Pre-op ref. 8 Other recommended medication orders from usual Anesthesia Preop order set based on level of pain or anxiety: Intra-operative Sublimaze 50mcg-100mcg IV PRN, or Hydromorphone 0.5-1mg IV PRN x 1 Pre-op PRN ref. 2, 7, 9, 11, 12 Methadone 5-10mg PO/IV ref. 2, 14 Midazolam 2m IV PRN for anxiety ref. 1,2 Anesthesiologist/Nurse Anesthetist (CRNA) Increase opioid by 2-4 times an Opioid naïve, or by 25-50% ref. 1, 4, 7, 9, 11, 12, 14 Multimodal analgesia: Acetaminophen/Ketorolac as appropriate ref. 1, 2, 4, 7, 9, 12, 11 Avoid Naloxone ref. 8,9

29 Post Anesthesia Care Unit (PACU) Nurse Assess, treat and reassess pain using increased opioid dose guidelines and multimodal medications ref. 1, 2, 7, 8, 9, 12 Goal to achieve pain goal or pain score less than 5 Use of non-pharmacologic techniques: Ice, Heat, Positioning ref. 1, 11, 13 Closely monitor respirations, oxygen saturation, and consider capnography ref. 12 Anesthesiologist/CRNA : Utilize Anesthesia Postop PORA Order Set: Hydromorphone 0.5-1mg IV Q 10 min prn with a max PACU dose of 4mg Sublimaze 25mcg-50mcg IV Q 5 min prn with a max PACU dose of 400mcg Morphine 2mg-5mg IV Q 5min with a max PACU dose of 20m Use of opioids postoperatively to treat pain at increased doses or 25-50% above baseline ref. 4, 7, 9, 11, 12 Reference List 1Mitra, S., & Sinatra, R. (2004). Perioperative management of acute pain in the opioiddependent patient. Anesthesiology, 101(1), Dykstra, K. (2012). Postoperative pain management in the opioid-tolerant patient with chronic pain: An Evidence-based practice project. Journal of PeriAnesthesia Nursing, 27(6), Swenson, J., Davis, J., & Johnson, B. (2005). Perioperative Care of the Chronic Opioid-Consuming Patients. Anesthesiology Clinic of North America, 23(2005), Bourne, N. (2008). Managing acute pain in opioid tolerant patients. Journal of Perioperative Practice, 18(11), Mancini, R., & Filicetti, M. (2010). Pain management of opioid-tolerant patients undergoing surgery. American Journal of Health-System Pharmacy, 67(11), p. doi: /ajhp090408

30 6Dumas, E., & Pollack, G. (2008). Opioid tolerance development: A pharmaokenetic/pharmacodynamic perspective. American Association of Pharmaceutical Scientists, 10(4) D Arcy, Y. (2010). Managing chronic pain in acute care, getting it right. Nursing, 40(4), Rozen, D., & Grass, G. (2005). Perioperative and intraoperative pain and anesthetic care of chronic pain and cancer pain. World Institute of Pain, 5(1), Richebe, P., & Beaulieu, P. (2009). Perioperative pain management in the patient treated with opioids: Continuing professional development. Canadian Journal of Anesthesia, 56, Noe, C., & MD, Williams, C. (2012). The Benefits of interdisciplinary pain management. Journal of Family Practice, 61(4), Jarzyna, D. (2005). Opioid tolerance: A perioperative nursing challenge. MedSurg Nursing, 14(6), Carroll, I., Angst, M., & Clark, J. D. (2004). Management of perioperative pain in patients chronically consuming opioids. Regional Anesthesia and Pain Medicine, 29(6), Pasero, C. (2013). Ketamine for refractory pain. Medscape. 14 Vaghari, B., Baratta, J. L., Gandhi, K. (2013). Perioperative Approach to Patients with Opioid Abuse and Tolerance. Anesthesiology News. Benjamin Vaghari,MD, Jaime L. Baratta, MD, Kishor Gandhi MD, MPH, CPE, (2013) Perioperative Approach to Patients with Opioid Abuse and Tolerance Anesthesiology News June Khan, Z. H., Rahim, M., Makarem, J., Khan, R. H. (2011). Optimal dose of Preincision/post-incision gabapentin for pain relief following lumbar laminectomy: a randomized study. Acta Anaesthesiologica Scandinavica 55(3), doi: /j x

31 IMPLEMENT EBP ON PILOT UNIT Process Improvement Detailed Plan Action Step Target Dates Who is Responsible Completed Comments Develop Care Path ALL 10/17/14 Create Document Checklist/screening tool April 2015 Ra Net Bye Heather Meece 4/15/15 Request for IS to make online version, will stay as paper until post implementation data can show an Anesthesia Order Set Committee members DR. Jaworowicz Steve Peneke Create Pt. Ed tool 4/15/15 Colleen Ewen 5/15/15 improvement 10/17/14 Online version completed 4/1/15 Get all approvals February Ra Net and Heather Meece Design Education Roll-out 4/10 Power Point complete May staff meeting conduct ed. Ra Net Bye Heather Meece 2/1/15 See key stakeholder list Power point 4/10/15 Staff Ed 5/4/15 All members of the Anesthesia staff and Surgical Neuro nurses received detailed Inform and Educate key stakeholders Implement New Care Path (30 days) Data Collection with new process April/May 2015 Ra Net Bye Heather Meece Prior to go-live May 18, 2015 ALL 5/18/15 September 1, days Ra Net Bye & Heather Meece Analysis of Data October 2015 Logan Fredrick Ra Net Bye & Heather Meece 10/30/15 /meetings/one on one 11/19/15 Results discussed with Shelly Malin/Logan Fredrick

32 EVALUATE PROCESS CHANGE AND OUTCOME(S) Post Implementation Data Collection Process Repeat Data Collection Process and goals as utilized for baseline data: Start with patients charts created in PAT on September 1, Collect for a total of 30 days or 30 patients. Patients having surgery will be screened by staff from PAT for inclusion criteria (attached). If patients meet the inclusion criteria, a data collection tool will be placed on the chart. Associates in each department will be responsible for filling in information as directed by the tool. All forms will be pulled from the chart in recovery and placed in a purple binder. Heather or Ra Net will collect forms and make a plan for interviewing patients the day after their procedure. Missing information will also be completed as able from the medical record. Completed forms will be placed in Ra Net s mailbox in the staff lounge. Heather and Ra Net will collected completed forms and enter data in an Excel spreadsheet. Data will be evaluated early in October and a decision on whether or not to extend the collection time period will be made. Staff education on the data collection process will be provided by Ra Net for SDS and PACU, and Sue for PAT in August. Education will be done during the daily staff huddle and will include the data collection plan and instructions for use of the data collection tool. Ra Net and Heather will predetermine patients having back/spine surgery through the use of the preoperative schedule. They will retrospectively compile a list of patients meeting inclusion criteria. This evaluation will test the application of inclusion /exclusion criteria by the Preadmission Testing staff. The data collection plan was reviewed and approved by the Chair of Anesthesia. After evaluating # of patients meeting inclusion may extend timeline to include at least 30 patients. MODIFY THE PRACTICE GUIDELINE(S) INSTITUTE THE CHANGE IN PRACTICE MONITOR AND ANALYZE STRUCTURE, PROCESS, AND OUTCOME DATA