Implementation of a Referral Criteria for Acute Pain Service

Abstract

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.