ORGANIZATION OF ACUTE PAIN SERVICE

Transcription

1 ORGANIZATION OF ACUTE PAIN SERVICE VIEW OF A NURSE Christine Sneyers UZ Brussel 15 june 2013 Symposium ACUTE PAIN: A Comprehensive Approach

2 Definition of Pain g An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. l Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. l Pain is that experience we associate with actual or potential tissue damage. l It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. IASP

3 What is Pain? Pain is whatever the person experiencing it says it is, existing whenever the person says it does. (McCaffery, 1968) Pain is a subjective experience and is probably the most bewildering and frightening experience kids will have.

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5 Rawal N, Berggren L. Organization of acute pain services a low cost model. Pain 1994;57: Unrelieved postoperative Pain may delay discharge and recovery - Result in an inability to participate in rehabilitation programs. - Recent studies show that under-treatment of pain continues, despite the availability of drugs and techniques for its effective management. - Recently, various medical and health care organizations have recommended a widespread introduction of Acute Pain Service (APS) - Furthermore, provision of an APS is presently a prerequisite for accreditation for training by the Royal College of Anaesthetists in the United Kingdom (UK) and the Australian and New Zealand College of Anaesthetists

6 Patients rigths 2002 Patients/Society more aware of their rights to have good pain control g We are being held accountable g JCAHCO standards, Pain is the Fifth Vital sign g Competence of staff in pain assessment and management g Educate patients and families g Guidelines for pain management after discharge

7 Guidelines American Society Of Anaesthesiologists l The revised ASA guidelines of 2004 highlighted the importance of multidisciplinary collaboration among anesthesiologists, surgeons, nurses, physical therapy, pharmacists and other members of the care team. l The visible presence of pain nurses increases patient satisfaction, improves pain control and safety, and may improve outcome. g Control pain, limit S/E and complications l Pressure from hospital to minimize length of stay l is grouwning

8 Role of APS Anesthesiologist l Expert knowledge l Train and support pain nurses, physician & anaesthetists l Respect guidelines l Lead multidisciplinary weekly ward rounds l Complications, complaints, questioned l Projects and teaching l Quality control l Statistics control

9 Nurse view on different levels: g Clinical g Organisational g Educational g Quality control g Audit

10 Clinical level

11 What is the Best Way to manage acute post-operative/trauma pain? l FIRST, DO NO HARM Therefore, the best way is a BALANCE Patient Safety Effective Analgesic Modalities J Penning MD FRCPC Director Acute Pain Service

12 KEY POINTS to Effective Pain Management l Emphasis is placed on the utilization of a multimodal analgesic approach to maximize analgesia while minimizing sideeffects. g Transduction g Transmission g Modulation g Perception l There is as of yet no single silver bullet!!

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14 Report recommendations: l Acute Pain Services should: g Be multi-disciplinary g Assume responsibility for management of postoperative pain l Acute Pain Service is a fullfledged Hospital Department. l It fills an essential hospital function, and as such be supported by branch hospital and fully funded from the budget of the hospital. l The direction of hospital approved protocols and guidelines and through decision trees, Acta Anesthesiology Belgica 2006

15 Do We Have a Problem? The medical profession sometimes find it difficult to believe the patient reporting pain. Copp 1990, Sofaer 1998 & Carter 1998.

16 Barriers to Effective Pain Management l Lack of knowledge l Inappropriate attitudes l Poor pain assessment l Notion that addressing pain takes too much time l Fears of adverse effects of analgesia respiratory depression, addiction l Personal values and beliefs; i.e. pain builds character l Pain management not a political issue! AAP 2001 Task Force on Pain in Infants, Children and Adolescents

17 Effective Acute Pain Management Stannard,C l In order to treat pain effectively it is necessary to assess it. l Pain is most effectively assessed by means of selfreporting : VAS is gold standard. l Always Assess Pain On Activity l Greater patient satisfaction, minimize S/E l Safer for the patient

18 Pain Scores l At rest l On movement l Deep Breathing l Coughing

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20 World Health Organization (WHO) Principles of Acute Pain Management l By the clock l With the patient l By the appropriate route l WHO Ladder of Pain Management

21 Acute Pain Management from a Nursing Perspective l Nurses are a key component of an acute pain service. g The pain nursing team may be composed of acute pain management nurses, pain resource nurses and floor nurses. g Clinical nurse specialist (advance practice nurse)

22 Pain is the Fifth Vital sign Nurse view l Pain must be assessed at regular intervals by the department nurses. ( Floor nurses) l Pain should be reassessed soon following an intervention to treat pain to ensure a response. l Pain assessments are required as a discharge criteria.

23 Example of Clinical Flowchart PACU C Sneyers- M Matic UZ Brusssel Anesthesiologist start paintherapy perioperative PACU nurses start evaluation with VAS VAS dynamic 3 PACU nurses start paintherapy VAS < 3 VAS 3 Criterium transfert Call PACU anesthesiologist for an adapted treatment Floor Nurses start evaluation with VAS/ 4h and continue paintherapy VAS < 3 VAS 3 APS nurses has been called and they check the treatment APS nurses call APS anethesiologist for an adapted treatment APS nurses visit patient the next day VAS < 3 VAS 3

24 Pain Resource Nurse Nurses specially trained in pain issues on each unit l Pain management resource to peers in the unit l Contact person with APNurse l Troubleshoots technical problems with infusion pumps l Enhances hospital initiative to extend aggressive pain management for all patients l Employs complementary techniques (i.e., relaxation, imaging, distraction)

25 Role of APS Nurse Pain Assessment: l Frequency l Pain scoring tool: VAS l Location of pain l Description of pain l Has the pain changed l Side effects l Review medication l What analgesia has the patient used previously l Patient s knowledge l Diagnosis

26 Acute Pain Management from a Nursing Perspective l Guidelines and protocols are intended to establish the basic standard of care and provide consistency in management. l Protocols prescribe methods of care in a less flexible way then guidelines, but neither is a substitute for depht personal knowledge. l Thoughtful application is essential if guidelines and protocols are to be safe and effective. l Standard orders and protocols are also provided to facilitate implementation of the suggested principles and approaches

27 With a nurse-driven acute pain service l The pain nurse is the first responder to calls for the patient s pain issues. l Pain nurses must possess astute assessment and critical thinking skills. This requires a background in critical care or postanesthesia care l PN must having the qualities of empathy, understanding and respect. l Be able titrating and bolusing as needed and removing catheters when indicated l All actions and interventions of the pain nurse are entirely within the scope of institutional protocols.

28 PCEA VAS DYN > 3!!! ZOEKEN NAAR HEELKUNDIG OORZAAK!!! CONTROLE SENSITIEVE BLOK NIVEAU = te laag of juist op chirugicale wonde: NIVEAU verhogen + CO- ADJUVENTIAs OK GEEN NIVEAU -DEBIET verhogen + reevaluatie -BOLUS programmeren Gedeeltelijk NIVEAU Begrip van Patiënt + medische bolus geven Décubitus: correkt? ja Oplaad DOSIS ½ debit x 2 / 15 Bolus programmeren Reevaluatie 30 SLECHTE LATERALISATIE - terugtrekken KT 1cm - min 4 cm IN peridurale ruimte - + med. bolus geven op pijnlijke kant 30 min.blijven. reevaluatie 30 VAS > 3 VAS < 3 OK VAS > 3 VAS > 3 VAS < 3 Sneyers-Matic UZB OK DECT APS anesthesist PCA IV? of ZENUW blok? débit en/of bolus? INFILTRATIE?

29 Ramsay Score/ Bromage score Pain nurses must be well trained at assessing hypotension, motor block and excessive sedation. Alert/awake = 0 Occasionally drowsy/slightly sedated = 1 Frequently drowsy/moderate sedated = 2 Difficult to rouse/severely sedated = 3 Stop infusion, contact APS nurse Reduce infusion rate, APS Nurse Observe ourly No intervention required Patient may be mobilise with supervision

30 ANATOMY Dermatomes Cuteanous nerves Utilizing decision trees and critical thinking, Are called upon to manage pain and side effects of pain therapies, Managing trouble-shoot epidural and peripheral block catheters

31 Acute pain nurse l Holds service pager and responds to calls for patients in pain or pain-related problems l Conducts frequent proactive assessments of analgesia and its side effects l Adjusts pain therapy or treatment of side effects according to a treatment algorithm and reassess efficacy of interventions l Point-of-care peer support to staff nurses

32 Daily practice with a APN l APN visit patient once or twice, l Respects the decision trees and flowcharts l Team discussion with pain physician once a day l Adapt treatment based anesthesiologist decisions l Visit control l Organizational meeting and discussion problem patients once a week l Suppose to assist in performing regional anesthesia techniques l No place for improvisation l An mandatory standard daily nurse clinical note is required to facilitate documentation

33 Organizational

34 Acute Pain Management from a Nursing Perspective l A nurse-driven acute pain service consists of a physician director ( anesthesiologist) and the nursing team working closely with the department of anesthesiology. l The anesthesiologist determines the appropriate analgesic technique.

35 APMS anesthesiologist director l Determines direction of service, l Defines and coordinates clinical, educational, and research goals, l Develops policies and protocols for pain assessment and treatment l Communicates with hospital administration, nursing service, and referring physicians l Reviews quality assurance indicators

36 Clinical nurse specialist (Advance Practice Nurse) l Coordinator of services providing continuity of care to APMS patients l Designs and implements educational programs for the department of nursing and patient education l Assists APMS director in development of goals, policies, protocols and standards

37 An example of APS organizationnal tree (C Sneyers- P Vanderlinden, CHU Brugmann, 2003)

38 l EDUCATIONAL

39 APMS attending staff l Is the critical link in providing education and peer support to the various members of the nursing service l Provides multiple educational sessions for the nursing staff of the hospital times annually l Informs the nursing staff of the hospital about all the changes in the protocols through the informational sessions l Presents the use of the good medical practice in the acute pain treatment

40 APM attending staff l Institutions are required to have policies and procedures for pain assessment and treatment. l Patient education for pain management is mandated. l Staff education concerning pain management is required.

41 Quality control

42 The quality control plan l APS nursing staff collects the data about the pain treatment, side effects and satisfaction score of the previously treated patients l All these datas are used to publish the results of the treatment once a 1 to 3 months l All these are also used to make annually report about the efficacy of the pain treatment l APS nursing staff are involved in making annually statistics l According to these results the adaptation of the protocols are done or new protocols are used

43 Management of pain requires a coordinated quality approach to meet the needs of patients C Sneyers- P Vanderlinden IBDU 2003

44 Audit l The APS nursing staff are closely involved in using the new protocols l Also communicating APS anesthesiologist regarding the results l APS anesthesiologist and APS nursing staff decide toegether of the implementation of the new protocols, new methods, new tecniques,

45 Adapt tecniques and protocols l Local anesthetic infusions must be prepared by the pharmacy and the continuous infusion be accomplished with an infusion pump. l In recent years, smaller electronic infusion pumps, elastometric pumps, and spring powered pumps have been designed for use in the ambulatory setting. l Because of the inherent risks of sending a patient home with an infusion device, most published studies, limit ambulatory use of the pumps to patients expected to have moderate to severe postoperative pain of a duration more than 24 hours, and whom will have difficulty managing the pain with oral opioids. l An alternative to continuous regional blocks is continuous infusion of local anesthetic directly into the wound site.

46 To improve l Not yet adequate pre-registration training on pain l High staff turnover l Wards very busy l Pain not seen as a priority l Less budget

47 Our hopes for the future l Find new ways to improve practice l Extend service to see all postoperative patients l Go to nurse prescribing l Work more closely with consultant physician l Nurse consultant leading the service l Participant in research and educational goals

48 l CONCLUSION

49 The Joint Commission on Accreditation of Healthcare Organizations and American Pain Society July 2000 Excuses for inadequate pain control appear to have run their course and will no longer be accepted because poor pain control is unethical, clinically unsound and economically wasteful.

50 l Thank you! l Dank u! l Merci!