• Implementation of a Referral Criteria for Acute Pain Service

      Alayev, Alina; Wiseman, Rebecca Fortune (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 Fortune (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.