An "Engage to Sustain" Intervention to Improve Process Performance Measures in Ambulatory Care.

In ambulatory care, monitoring process performance measures (PPMs) is essential to meet regulatory requirements, establish targets for care, seek reimbursement, and evaluate patient care responsibilities. We implemented a comprehensive program, "Engage to Sustain," for licensed practical nurses (LPNs) and certified medical assistants (CMAs) to practice at the top of their licensure/certification. Screening rates for 4 key PPMs (depression screening, fall risk screening, and tobacco use screening and counseling) markedly increased following this intervention across 18 ambulatory departments with more than 2 million patient visits. These results suggest that shifting responsibilities for patient screening from physicians and advanced practitioners to LPNs and CMAs may improve screening rates.

The Prevalence, Intensity, Assessment, and Management of Acute Pain in Hospitalized Children in Botswana.

BACKGROUND: There is very limited clinical and observational data on acute pain experienced by children in sub-Saharan Africa. AIMS: To report the prevalence and intensity of acute pain, pain management practices, and describe associations between acute pain outcomes, children's and parents or guardian's demographics in hospitalized children aged 2 months to 13 years in Botswana. DESIGN: A descriptive correlational prospective observational study using five repeated cross-sectional samples. SETTINGS: Two referral hospitals in Botswana. PARTICIPANTS: The sample size included 308 children and 226 parents or guardians. Data were collected between November 2018 and February 2019 from children, their parents or guardians (<7 years child), and the health record for pain documentation and treatment. MEASURES: Pain was measured using Faces Pain Scale-Revised for children ≥7 years, revised Face, Legs, Activity, Cry, Consolability scale for children <7 years and numeric rating scale for parents or guardians. RESULTS: There are 1,290 data points for children of which 1,000 were children <7 years and 999 data points for parents or guardians of children <7 years were used in analysis. Fifty percent of children <7 years were in pain using the revised Face, Legs, Activity, Cry, Consolability scale, whereas parents indicated 46% to be in pain. The pain prevalence for children ≥7 years was estimated at 54%. Pain was documentated at a rate of 54 % on the health records. Acetaminophen was most common analgesic across all age groups. Univariate associations of child <7 years pain intensity was statistically significant (p ≤ .05) for weight, diagnosis, residence, and parent relationship. Parents reported pain intensity was statistically significant (p ≤ .05) for child sex, weight, diagnosis, residence, surgery, parent or guardian age and education. Only age and surgery were significant for children ≥7 years. CONCLUSIONS: Acute pain prevalence and intensity among hospitalized children in Botswana is low.

A Multivariate Analysis of Pain and Distress in Adults Undergoing BMAB.

Clinicians routinely perform bone marrow aspiration and biopsy (BMAB) to diagnose cancer and evaluate disease status; however, few studies address pain and distress with BMAB. A prospective descriptive-correlational design examined patients' (N = 152) ratings of pain intensity (numeric rating scale, 0-10) and distress (distress thermometer) at baseline and 5 min and 1 hr postprocedure. Data were analyzed using descriptive statistics, chi-square, and linear regression models. Mean postprocedure pain intensity at 5 min was moderate, 5.56 (SD = 3.03), and opioid use was associated with decreased pain at 1 hr (p < .001). Preprocedure administration of anxiolytics had no significant effect on distress reduction (p = .88). Being female, first-time biopsy, and increased preprocedure pain were significant predictors of postprocedure distress (p < .001). Treating anxiety alone may not be sufficient to lessen pain and distress. Individualized plans of care should be based on patient risk and response to procedure.

Preliminary Psychometric Evaluation of the Nurse Anesthesia and the Aftermath of Perioperative Catastrophes Survey and the Ways of Coping Questionnaire.

The National Academy of Medicine recognizes medical errors as a leading cause of death in the United States. Hospitals nationwide have acted to improve patient safety, quality of care, and system processes; however, no standards mandate assessment of the emotional impact of perioperative catastrophes on healthcare professionals. A cross-sectional descriptive study using a sample of 196 Certified Registered Nurse Anesthetists (CRNAs) tested the psychometric properties of an adapted version of the Perioperative Catastrophes Survey and administered this survey along with the Ways of Coping Questionnaire to measure CRNAs' perceptions, experiences, and responses associated with perioperative catastrophes. The adapted survey demonstrated acceptable internal consistency reliability (α = .893) and construct validity (factor analysis), with 4 subscales explaining 68.1% of the variance in the measure. The CRNAs scored similarly to anesthesiologists in a prior study conducted by Gazoni and colleagues, showing that memorable perioperative catastrophes have a negative emotional, cognitive, and functional impact. On the 8 Ways of Coping Questionnaire subscales, CRNAs with less than 10 years of experience reported significantly higher Escape-Avoidance behaviors compared with more experienced CRNAs (P = .016). Future research must examine perceptions of perioperative catastrophic events and coping mechanisms to identify providers at risk of negative consequences.

Evaluating the use of dexmedetomidine for the reduction of delirium: An integrative review.

Delirium, an acute change in cognition and attention not secondary to a pre-existing condition or dementia, affects nearly 40,000 hospitalized older adults in the United States every day. Delirium is associated with increased healthcare costs of $16,303 to $64,421 per patient. To date, no single pharmacological intervention is effective in preventing or treating delirium in critically ill patients. Evidence suggests the alpha-2 agonist, dexmedetomidine, may reduce or prevent delirium. An integrative review examined whether dexmedetomidine was associated with a lower incidence of delirium compared to other analgesic and sedation strategies. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guided this review and 16 publications met quality criteria for inclusion. These studies support that postoperative administration of dexmedetomidine may reduce delirium in patients, particularly following cardiac surgery. Further research is needed to determine the benefits of dexmedetomidine in patients on mechanical ventilation and optimal timing and duration of administration.

Acute Pain Medicine in the United States: A Status Report.

BACKGROUND: Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. METHODS: A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education. RESULTS: The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM. CONCLUSION: This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.

Does Regional Anesthesia Improve the Quality of Postoperative Pain Management and the Quality of Recovery in Patients Undergoing Operative Repair of Tibia and Ankle Fractures?

OBJECTIVES: To determine whether the use of peripheral nerve blocks (PNBs) as part of an analgesic protocol for operative repair of tibia and ankle fractures can improve the quality of postoperative pain management and the quality of recovery (QOR). STUDY DESIGN: Prospective cohort study. SETTING: Orthopedic trauma service in an academic tertiary care center. PATIENTS: Ninety-three consecutive patients undergoing operative repair of fractures of the ankle and tibia. INTERVENTION: Administration of popliteal and saphenous nerve blocks, as part of postoperative analgesia regimen in some patients. Patients were labeled as the regional group or the no-regional group based on whether they received PNBs. OUTCOMES: Patient satisfaction and the quality of pain management were measured 24 hours after surgery using the Revised American Pain Society Patient Outcome Questionnaire. The QOR was measured at 24 and 48 hours after surgery using the short version of the Quality of Recovery Questionnaire (QOR-9). RESULTS: Satisfaction with pain management was significantly higher (P = 0.005) in the regional group when compared with the no-regional group. Average pain scores over 24 hours was similar between the 2 groups (P = 0.07). The regional group reported less time spent in severe pain over 24-hour period (40 vs. 50%, P = 0.04) and higher overall perception of pain relief (80 vs. 65%, P = 0.003). Patients receiving regional anesthesia also demonstrated better QOR measured by the QOR-9 at 24 hours (P = 0.04) but not at 48 hours (p = 0.11). CONCLUSIONS: Patient satisfaction and the quality of postoperative pain management for the first 24 hours were better in patients who received PNBs as part of their postoperative analgesic regimen when compared with patients who received only systemic analgesia. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Nursing's role in cancer pain management.

Nurses have advanced practice, research, and education in the field of cancer pain management. This paper highlights the contributions nurses have made to pain science and practice through literature published in the past 3 years. Work accomplished by nurses is examined in the areas of pain assessment, pain management, intervention-based research, evidence-based practice, patient education, and palliative care. Nurses serve as advocates for empowering patients to engage in self-management of their pain, and offer education and support to patients and families at their most vulnerable times. Nurse researchers have been at the forefront of work to develop and test new instruments and approaches to measure pain, elucidate pain experiences through quantitative and qualitative methodologies, and gauge the quality of pain care for patients and its impact on their caregivers. This research has uncovered many patient, health care professional, and systemic barriers to effective pain control, and has offered feasible solutions to overcoming these barriers.

Effect of body position on cerebral oxygenation and physiologic parameters in patients with acute neurological conditions.

How body position influences brain tissue oxygen (PbtO2) and intracranial pressure (ICP) in critically ill neurosurgical patients remains poorly defined. In a prospective observational repeated measures study, we examined the effects of 12 different body positions on neurodynamic and hemodynamic outcomes. Thirty-three consecutive patients (mean +/- SD, age = 48.3 +/- 16.6 years; 22 men), admitted after traumatic brain injury, subarachnoid hemorrhage, or craniotomy for tumor, were evaluated in a neurocritical care unit at a level 1 academic trauma center. Patients were eligible if the admission score in the Glasgow Coma Scale was < or =8 and they had a Licox CMP Monitoring System (Integra Neurosciences, Plainsboro, NJ). Patients were exposed to all 12 positions in random order. Changes from baseline to the 15-minute postposition assessment mean change scores showed a downward trend for PbtO2 for all positions with statistically significant decreases observed for supine head of bed (HOB) elevated 30 degrees and 45 degrees (p < .01) and right and left lateral positioning HOB 30 degrees (p < .05). ICP decreased with supine HOB 45 degrees (p < .01) and knee elevation, HOB 30 degrees and 45 degrees (p < .05), and increased (p < .05) with right and left lateral HOB 15 degrees. Hemodynamic parameters were similar in the various positions. Positioning practices can positively or negatively affect PbtO2 and ICP and fluctuate with considerable variability among patients. Nurses must consider potential effects of turning, evaluate changes with positioning on the basis of monitoring feedback from multimodality devices, and make independent clinical judgments about optimal positions to maintain or improve cerebral oxygenation.

A comparison of change in the 0-10 numeric rating scale to a pain relief scale and global medication performance scale in a short-term clinical trial of breakthrough pain intensity.

BACKGROUND: Pain intensity is commonly reported using a 0-10 Numeric Rating Scale in pain clinical trials. Analysis of the change on the Pain Intensity Numerical Rating Scale as a proportion has most consistently correlated with clinically important differences reported on the patient's global impression of change. The correlation of data from patients with breakthrough pain with a Pain Relief Scale and a different global outcome measures will extend our understanding of these measures. METHODS: Data were obtained from the open titration phase of a multiple crossover, randomized, double-blind clinical trial comparing oral transmucosal fentanyl citrate with immediate-release oral morphine sulfate for the treatment of cancer-related breakthrough pain. Raw and percentage changes in the pain intensity scores from 1,307 episodes of pain in 134 oral transmucosal fentanyl citrate-naïve patients were correlated with the clinically relevant secondary outcomes of Pain Relief Verbal Response Scale and the global medication performance scale. The changes in raw and percentage change were assessed over time and compared with the ordinal Pain Relief Verbal Response Scale and Global Medication Performance Scale. RESULTS: The P value of the interaction between the raw pain intensity difference was significant (P = 0.034) for four 15-min time periods but not for the percentage pain intensity difference score (P = 0.26). We found similar results in comparison with the ordinal Pain Relief Verbal Response Scale (P = 0.0048 and P = 0.36 respectively) and global medication performance categories (P = 0.048 and P = 0.45, respectively). CONCLUSION: The change in pain intensity in breakthrough pain was more consistent over time and when compared with both the Pain Relief Verbal Response Scale and the Global Medication Performance Scale when the percentage change is used rather than raw pain intensity difference.

Development and validation of a new instrument to evaluate the ease of use of patient-controlled analgesic modalities for postoperative patients.

OBJECTIVE: To describe the development and psychometric evaluation of a questionnaire assessing the ease of use that patients associate with patient-controlled analgesia (PCA) modalities. METHODS: Qualitative interviews were conducted with patients who had experience with intravenous (IV) PCA for postoperative pain management to generate items relevant to the ease of using PCA modalities. The content validity of the resulting questionnaire was examined through follow-up patient interviews, and an expert panel reviewed the questionnaire. Cognitive debriefing interviews were conducted with patients to determine the clarity and content of the instructions, items, and response scales, and the ease of completing the instrument. Psychometric evaluation was performed with patients who had undergone surgery and received IV PCA for postoperative pain management. Item and scale quality and the internal consistency reliability of the questionnaire were assessed. Construct validity was evaluated by examining the relationship between subscales of the questionnaire with patient-reported outcome measures. Known-groups validity was determined by assessing the instrument's ability to differentiate between patients with versus without an IV PCA problem. A potential limitation of this study was the exclusive sampling of patients who had experience with IV PCA. RESULTS: The Patient Ease-of-Care (EOC) Questionnaire included 23 items in the following subscales: Confidence with Device, Comfort with Device, Movement, Dosing Confidence, Pain Control, Knowledge/Understanding, and Satisfaction. Coefficient alpha reliability estimates were ≥ 0.66 for Overall EOC (includes all subscales except Satisfaction) and all EOC subscales. Construct validity was supported by the moderate relationship between the Pain Control subscale and measures of pain severity and pain interference; additional evidence of construct validity was provided by correlations of the Confidence with Device subscale, the Satisfaction subscale, and Overall EOC with measures of pain severity, pain interference, and satisfaction. Significant mean score differences were reported between participants with and without IV PCA problems for Overall EOC and for the Comfort with Device, Confidence with Device, Movement, Pain Control, and Satisfaction subscales indicating known-groups validity. CONCLUSIONS: Results provide evidence for the reliability and validity of the Patient EOC Questionnaire as a measure of the ease of use that patients associate with PCA systems and may be useful for evaluating emerging PCA modalities.

Perspective on pain management in the 21st century.

Pain is a predictable consequence of surgery or trauma. Untreated, it is associated with significant physiologic, emotional, mental, and economic consequences. Despite the vast amount of current knowledge, uncontrolled postoperative pain is reported by approximately 50% of patients. Thus, techniques for effective acute pain management (APM) represent unmet educational needs. The significance of this unmet need is reflected in the number of journal and textbook publications dedicated to disseminating research, evidence-based guidelines, and clinical information. Acknowledging the importance of APM, health care accrediting agencies and professional societies have become increasingly focused on ensuring that patients receive prompt and acceptable pain relief.

Pharmacotherapy for acute pain: implications for practice.

Effective treatment of perioperative acute pain requires that information about the patient's goals for pain relief, previous history with analgesics, and type of surgical procedure is used to guide decisions about analgesic regimens. Analgesics are selected based on the location of surgery, degree of anticipated pain, and patient characteristics (such as comorbidities), and routes of administration and dosing schedules are determined to maximize the effectiveness and safety of analgesia while minimizing the potential for adverse events. Pain management therapy is then extended into the postsurgical phase of recovery. To accomplish this, nurses must have a thorough understanding of the pharmacology of analgesics. This article provides useful information for commonly used analgesics, primarily nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and local anesthetics for control of acute postoperative pain.

Obesity in nursing homes: a critical review.

Obesity is a significant, and increasing, health problem for older individuals, their caregivers, and healthcare professionals and delivery systems, yet few studies document how nursing homes have responded to this epidemic. To address these gaps, an extensive electronic search was conducted in the Cumulative Index of Nursing and Allied Health, MedLine, PubMed, and the Cochrane Library using key terms and phrases, including obesity, morbid obesity, obesity in elderly, long-term care, bariatric or weight loss surgery, nursing care, and nursing homes. Subsequent critical review suggests that research on obesity in older adults has predominantly been conducted in community-dwelling populations and that few investigations have elucidated this problem in nursing home (NH) residents. Research priorities are also proposed to fill the current void in studies of obese NH residents.

Pharmacotherapy for acute pain: implications for practice.

Effective treatment of perioperative acute pain requires that information about the patient's goals for pain relief, previous history with analgesics, and type of surgical procedure is used to guide decisions about analgesic regimens. Analgesics are selected based on the location of surgery, degree of anticipated pain, and patient characteristics such as comorbidities, and routes of administration and dosing schedules are determined to maximize the effectiveness and safety of analgesia, while minimizing the potential for adverse events. Pain management therapy is then extended into the postsurgical phase of recovery. To accomplish this, nurses must have a thorough understanding of the pharmacology of analgesics. This article provides useful information for commonly used analgesics, primarily nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and local anesthetics for control of acute postoperative pain.

Perspective on pain management in the 21st century.

Pain is a predictable consequence of surgery or trauma. Untreated, it is associated with significant physiological, emotional, mental, and economic consequences. Despite the vast amount of current knowledge, uncontrolled postoperative pain is reported by approximately 50% of patients. Thus, techniques for effective acute pain management (APM) represent unmet educational needs. The significance of these unmet needs is reflected in the number of journal and textbook publications dedicated to disseminating research, evidence-based guidelines, and clinical information. Acknowledging the importance of APM, health care accrediting agencies and professional societies have become increasingly focused on ensuring that patients receive prompt and acceptable pain relief.

Measuring patient-oriented outcomes in palliative care: functionality and quality of life.

Outcomes measurement is necessary to evaluate quality of care, increase knowledge about experiences with cancer and therapies, and determine the effectiveness of interventions directed toward improving symptoms and quality of life (QOL) in research and clinical care. Recent attention on outcomes measurement and research in palliative care settings has emphasized the need to incorporate patient-reported outcomes. Unlike other areas of research in oncology, palliative care research is comprised largely of descriptive studies elucidating the process involved with palliative care, with a notable void in well-designed patient-oriented studies employing standard instruments for measuring functional status, QOL, symptoms, and psychosocial well-being. Outcomes programs in practice settings where palliative care is an integral part of clinical services can offer important information about patient experiences across the continuum of care and help to identify patients most likely to benefit from palliative care interventions. Therefore, oncology nurses must be informed about outcome-measurement issues, including ways to select reliable and valid instruments and determine which ones are appropriate for palliative care populations. Content related to the measurement of patient-oriented outcomes is presented to assist nurses in developing outcomes programs in palliative care settings.

Palliative care and end-of-life care World Wide Web resources for geriatrics.

As the average life span of Americans increases, there is a tremendous need for geriatric- specific information and resources, especially for those older adults with life-limiting illnesses. Emerging literature underscores the differences in palliative and end-of-life approaches between younger and older adults in treating symptoms, understanding issues related to psychosocial and spiritual well-being, and alleviating caregiver burden. Hundreds of internet sites currently exist that pertain to geriatrics, and health professionals now have access to evidence-based clinical care guidelines, guides for education and training, and networks to support patients and their families. Even consumer-oriented organizations have assumed responsibility for informing patients and families and outlining supportive care services for patients and families. This paper reports the results of a systematic evaluation and critique of 15 websites, and summarizes their unique contributions clinical care guidelines, teaching materials and training opportunities, effective models of care, and advice on dealing with the complex emotional, social and financial issues facing older adults at the end-of-life.