• Effectiveness of an Electronic Pain Notification System on Postoperative Pain

      Paranilam, Sheeba Ouseph; Johantgen, Mary E. (2013)
      Background: Pain management is an important responsibility of the entire health care team. A 2008 nursing documentation audit at the study hospital showed inadequate pain assessment. In response, an Electronic Notification System (ENS) for Registered Nurses (RNs) was implemented in one surgical unit of the study hospital in 2008-2009. Purpose: The purpose of this study was to determine the effectiveness of the ENS on postoperative pain measurements, pain intensity, and total narcotic analgesic use. Furthermore, the association between pain control and patient outcomes such as physical therapy participation, length of hospitalization, and discharge disposition was examined. Methods: A retrospective, descriptive-correlational design used medical record data to compare postoperative pain and related outcomes before and during the ENS implementation. Hospitalized inpatients undergoing hip or knee joint replacement, laminectomy, or spinal fusion were studied. The pre-ENS group included 95patients, whereas the ENS group had 113 patients. Linear mixed modeling was used to account for the repeated pain observations clustered within patients, while controlling for potential covariates. Results: There were no significant differences in frequency of pain measurement nor in pain intensity between the pre-ENS and ENS time periods. However, other important covariates were found to significantly influence pain intensity including history of mental illness (t=2.028, p=.045), pre-operative opioids (t=3.307, p<.001), and age (t= -3.383. p<.001). Only age (t=3.406, p<.001) and pain level on day 2 (t=2.306, p= .025) were significant predictors of length of stay. Conclusion: While the use of an electronic notification system reflects a widely used technology, the effectiveness was not demonstrated in this population and setting. The findings showing that patients with a history of mental illness and opioid use report higher pain intensity, confirm the findings of previous studies and should be incorporated in developing customized pain management plans. Innovative new devices such as ENS could be a valuable tool to assist nurses in pain assessment and documentation but current evidence does not support their use.
    • The Effects of Reiki on Stress and Pain in the Hospitalized Trauma Patient

      Foster, Dawn; Thomas, Sue Ann, 1947- (2010)
      Stress and pain can detrimentally impact the recovery of patients in the hospital setting. Complementary and Alternative Medicine (CAM) therapies have seen an upsurge in healthcare settings. The utilization of Reiki is increasingly employed in hospitals to assist in the alleviation of stress and pain for hospitalized patients. Although progressively used with hospitalized patients, little scientific evidence as to the efficacy of this practice has been established. This study examines the effects of Reiki on both physiological measures of stress and pain (blood pressure and heart rate) and subjective measures (pain scores, amount of pain medication utilized and the State Anxiety Inventory) in hospitalized trauma patients. A quasi-experimental repeated measures study was conducted in the trauma setting. Adults (8 males and 2 females) between 23 and 59 years participated in Reiki and Standard of Care (SOC) visits on 4 consecutive days. Subjects either received Reiki or Standard of Care on day 2 and the alternate on day 3. Blood pressure and heart rate were recorded 12 times, four times during each session, with pre and post pain scores. The amount of pain medication utilized in the previous 24 hours prior to each session was recorded, as well as, the post-session State Anxiety Inventory. No significant relationship was found between age and anxiety levels (p>.05). State anxiety at the final session was found to be significantly lower than at the baseline session (p<.05). Results offered no support that Reiki reduced the need for pain medication in this population (p>.10). No significant differences were found in heart rate and blood pressure either during sessions (p>.10) or between those receiving Reiki and those monitored for SOC (p>.10). While this study offers no support to the utilization of Reiki as an intervention for stress and pain in the hospitalized trauma patient, a discussion as to the problems and pitfalls of clinically-based research and the use of CAM is presented.
    • Exploring Parental Perceptions Regarding Surgical Pain Management Practices in a University Pediatric Inpatient Setting

      Simone, Shari (2011)
      Background: Reports of inadequate pain assessment and management have resulted in the development of regulatory and professional standards and guidelines about pain management. However, there continues to be a high prevalence of pain in hospitalized children and continued evidence that parents perceive pain management to be suboptimal. Low parental satisfaction with pediatric pain management at a large academic medical center prompted the need for practice improvement. Although, identifying gaps in best pain practices are critical to reducing pain in hospitalized children, strategies to improve satisfaction must include understanding the perceptions and expectations of parents to improve organizational performance related to patient and family satisfaction. Purpose: The objective of this capstone project was to explore parental perceptions regarding surgical pain management. Design: A descriptive, non-experimental survey was used to interview parents of children with acute surgical pain management. Sample: A convenience sample of 30 parents of post-surgical children admitted to the pediatric inpatient units at a large academic medical center was interviewed. Methods: An assessment survey was developed for the purpose of this project and underwent content validation by a series of experts. Structured interview conducted up to 48 hours after surgery. A subset of parents (n=ll) whose child received patient-controlled analgesia (PCA) was re-interviewed after discontinuation. Results: Post-operative pain occurred in 96.7% of the children, of whom one-half experienced moderate pain some or most of the time in the 24 hours prior to the interview. Eighty percent of the parental subset reported their child had pain some to most of the time after the PCA was discontinued. Although, 67% of the parents (n=20) were completely satisfied with the nurse's pain management at the first interview, 6 of these parents reported decreased satisfaction during the second interview. Parents of children whose post-operative pain was managed by the pain team were very satisfied with the early post-operative pain management; however, pain relief was perceived as less effective in the late post-operative period when managed by the surgical team. Forty percent of parents from both interviews identified earlier pain treatment, alternative pain treatment options and increased nursing availability as areas for improvement. Implications: Parental perception of suboptimal pain control warrants improvements in pediatric pain management. The parental suggestions for improvement opportunities provide valuable information in designing QI strategies to optimize pediatric pain management unit practices. Findings also suggest the need for improved collaboration with the pain team during the first 24- hours after transition from PCA to around-the-clock analgesia. In addition, development of best practice pain protocols to standardize care for the pediatric surgical population may smooth transitions in pain management.
    • Grand Round Lecture: The Placebo Phenomenon: From Clinical Trial Designs to Laboratory Research

      Colloca, Luana (2016-11-16)
      Objectives •Understand how to interpret placebo responses in the context clinical trials •Learn about the psychoneurobiologicalaspects of placebo effects •Familiarize with potentials for translating lab research knowledge into tips for daily clinical practice
    • Implementation of a Referral Criteria for Acute Pain Service

      Alayev, Alina; Wiseman, Rebecca (2019-05)
      Background: In the United States, pain affects more people than heart disease, diabetes, and cancer combined. Inadequate pain control has many adverse consequences, such as delay in recovery, prolonged length of stay in the hospital, increased medical costs, increased risk of immobility, anxiety and depression, sleep deprivation, and an overall decrease in quality of life. Acute Pain Service (APS) has been shown to lead to better pain management in hospitalized patients. All healthcare facilities are recommended to establish an Acute Pain Service team to provide adequate pain management to the patients. Local Problem: The community hospital where this Doctor of Nursing Practice (DNP) project took place has established an APS team. However, it is being widely underutilized. Pre-implementation data showed a less than thirteen percent Acute Pain Service referral rate on the acute inpatient cardiac telemetry unit. The goal of this project was to implement a referral criteria tool to increase the utilization of the Acute Pain Service on a cardiac telemetry unit in a community hospital in Maryland. Interventions: A quality improvement project took place over a 14-week period on a cardiac telemetry unit. The referral criteria tool was printed out and distributed to all unit staff. DNP student provided educational opportunities for the pain champions, who were designated by the unit manager, who served as resources for the unit nurses on the role and benefit of Acute Pain Service. Nurses assessed patients upon admission and after a change in status using the referral criteria tool to determine if they qualified for an Acute Pain Service referral. Inclusion criteria were patients on chronic opioids, patients receiving patient-controlled analgesia (PCA), patients who were active substance abusers, and patients with uncontrolled pain. Meeting at least one of the criteria qualified a patient for the referral. Nurses would then request a consult from the provider during daily multidisciplinary rounds. DNP student project coordinator was on the unit weekly to provide support, answer any questions, and collect data. Results: A total of 214 patients, who were admitted on the unit during the eight week implementation period, were evaluated to determine if they met Acute Pain Service referral criteria by performing Electronic Medical Record chart audits. A total of 20 patients met referral criteria with 11 of them receiving a consultation by Acute Pain Service (55%). Pre-implementation data on this unit showed an overall 12.7% Acute Pain Service referral rate, with eight out of 63 qualifying patients referred to Acute Pain Service in a four-month period leading up to this DNP project. The difference was found to be statistically significant using Chi-squared test (p<0.001). Conclusions: The implementation of the referral criteria instrument increased the Acute Pain Service referral rate from 12.7% pre-implementation to 55% post-implementation. The recommendation is to continue using the referral criteria tool and eventually make it a hospital-wide assessment tool that is integrated into the Electronic Medical Record.
    • Implementation of a Referral Criteria for Acute Pain Service on a Post-Surgical Inpatient Unit

      Smith Azarcon, Sharon-Marie; Wiseman, Rebecca (2019-05)
      Background One in every four Americans experience pain for greater than 24 hours. Pain is a major reason Americans access the health care system. Uncontrolled pain can lead to longer hospital stays, increased rate of readmissions, and increased risk of arising complications. Acute Pain Service (APS) is a team that can manage patient’s pain during the hospital stay. APS is found to decrease length of hospital stay and improve pain management in patients. A referral criteria instrument is a tool that guides nurses in assessing patients that meet criteria for APS. This referral criteria instrument can assist in increasing the number of APS consults. Local Problem Low APS consults were observed to be a practice problem in a post-surgical unit of a community hospital. In addition, the unit was observed to have uncontrolled pain as indicated by low patient satisfaction scores collected from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The hospital has an approved referral criteria instrument that nurses could access to determine if patients meet criteria for a referral to Acute Pain Service (APS). However, nurses were resistant to the APS team due to the misperception of pain medication administration and nurses believing that utilizing APS for pain management led to opioid addiction. Interventions This quality improvement project took place over a 14-week period. During weeks 1-2, training on referral criteria via informal meetings was given to the clinical site representative, unit manager, pilot team (i.e. nurses on the unit), and pain champions on the unit. Printed copies of the referral criteria instrument were posted in the nurses’ station, nurses’ break room and walls of the bathroom. Implementation of the project occurred during weeks 3-10. The pilot team was reminded to utilize the referral criteria instrument daily. Patients that met criteria for APS were discussed during daily interdisciplinary rounds. Weeks 11-14 consisted of data collection and analysis for the project. Results The post implementation of the referral criteria instrument revealed an increase in the percentage of patients consulted to APS. Post-implementation results showed that 53.7 % of patients were consulted to APS, compared to pre-implementation results of 25.3% of patients consulted to APS. Findings revealed that the difference was statistically significant using the Chi-Squared test, p = 0.002 (p< 0.05). Conclusion The implementation of the referral criteria for APS was beneficial to the unit based on the increase of APS consults. The percentage of consults to APS post implementation was 53.7 %. This was a 28.4% increase of APS consults on the unit. Training on the referral criteria instrument and understanding the purpose of APS gave positive outcomes for the unit by increasing APS consults on patient that met criteria for APS. In addition, the increase in APS consults should furthermore lead to increased patient satisfaction and increased HCAHPS scores.
    • Palliative Care Consultation in Pediatric Stem Cell Transplant

      Lafond, Deborah A. (2012)
      Purpose: The purpose of this project was to investigate the feasibility of a proposed practice change to integrate early palliative care consultation that would promote transcendent comfort in children and adolescents with advanced or high-risk cancers or other non-malignant diseases undergoing hematopoietic stem cell transplantation (HSCT). Background and Significance: Hematopoietic stem cell transplantation (HSCT), a modality used to treat a variety of advanced cancers and other serious non-malignant diseases in children and adolescents, may have significant symptom distress. The goal of enhanced comfort is the utmost concern of children and adolescents undergoing HSCT and their families (Mayer, Tighouart, Terrin, Stewart, Peterson, Jeruss, & Parsons, 2009). Multiple pediatric professional organizations have set a standard to promote relief of symptom distress and promote quality of life and enhanced comfort (AAP, 2000; Freibert & Huff, 2009). Clinical research on the effectiveness and benefits of interventions to relieve symptom distress is paramount to expanding the evidence base of pediatric palliative care and the science of HSCT in prioritizing comfort. Methods: A single-site, feasibility study was used to examine the primary aims of (1) willingness of patients and families of a vulnerable population to receive the palliative care intervention, (2) willingness of the health care team to refer families, (3) resource allocation, and (4) family and provider satisfaction. Secondary aims included evaluation and concordance of comfort from parent and child perspectives. A convenience sample of 12 families (child undergoing HSCT and their parent) were enrolled on the study. Data collection included referral and enrollment patterns, and time and resources required for palliative care interventions. Additional data included child self-report and parental reports of their child's comfort at baseline, T1 (~14 days following HSCT), and T2 (~ 30 days following HSCT). Family and provider satisfaction were measured at the end of enrollment. Findings: 100% of eligible families were referred and consented to participate (N = 12). Each family received a minimum of one visit per week, however, an average of 3 visits per week were made. Visits ranged from 15 minutes to 2 hours, depending upon individual circumstances. The top interventions requested or required, in addition to standard HSCT care interventions, included supportive care counseling, massage therapy, aromatherapy, play therapy, acupuncture, acupressure, and other integrative medicine techniques. Children and adolescents consistently rated comfort as "very good", however, parents tended to rate their child's level of comfort lower. There were 3 deaths of participants during the study. Families and providers expressed high satisfaction with this approach to care. Conclusion: This intervention is a novel approach to providing early palliative care services with curative intent therapy. Early palliative care intervention was well received by providers and families of children undergoing HSCT. Parents rate their child's level of comfort somewhat lower than child self-report, however, distress of parents impacts the entire family system thus interventions aimed at improving the child's comfort may improve parental distress and support better family functioning. Early palliative care services helped palliative care practitioners better meet the needs of the families who experienced the death of their child. Because of this additional support, end of life was peaceful and coordinated. This approach to care will be integrated as a standard of care for HSCT at the study site.
    • Pilot Study: The Effect of Education on the Knowledge and Attitudes of Nurses Regarding Pain

      Gift, Kathryn (2014)
      Pain affects more than 76 million adults in the United States and is the number one reason people seek medical attention (Joint Commission, 2013, Zacharoff, Pujol, & Corsini, 2010). Although pain management is considered a top priority in health care, it continues to be inadequately addressed (Duke, Haas, Yarbrough, & Northam, 2013). The basis for nursing intervention and a critical component of effective pain management is pain knowledge and assessment (Al-Shaer, Hill, and Anderson, 2011). A nurse’s perception of pain can be influenced by their knowledge and past experiences of pain, the patient’s demographic (Manias, Botti, & Bucknall, 2002) as well as the nurse’s years of experience and degree preparation (Al-Shaer, Hill, & Anderson, 2011). The purpose of this quality improvement pilot study is to determine if the presentation of a three hour class titled Pain Types, Assessment, and Management will enhance nurse’s knowledge regarding pain. In this single group pretest/posttest design, the 37 item Knowledge and Attitudes Survey Regarding Pain (KASRP) survey tool (Ferrell & McCaffrey, 2012) was used for both the pretest and posttest. A paired-samples t-test was conducted to evaluate the impact of pain education intervention on the scores of the KASRP. There was a statistically significant increase in KASRP scores from the pretest (M=21.72, SD=3.46) to the post test (M=23.50, SD =3.66), t (17) = -2.618, p <.05 (two- tailed). The mean increase in KASRP scores was 1.77 with a confidence interval from 3.21 to 3.45. Future educational offerings as well as quality improvement projects will be generated based upon the findings.