Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial.

OBJECTIVE: To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies. DESIGN: A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only. SETTING: Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership. PARTICIPANTS: Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group. MEASUREMENTS: Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later. RESULTS: Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention. CONCLUSIONS: Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

Intrathecal hydromorphone for intractable nonmalignant pain: a retrospective study.

BACKGROUND: Hydromorphone is often administered intrathecally for the treatment of cancer and nonmalignant chronic intractable pain. It is frequently utilized in combination with other analgesics in a multidrug intrathecal infusion; however, very little data are available documenting efficacy or safety of intrathecal hydromorphone as a solo analgesic. OBJECTIVE: This study was conducted to examine pain and side effects in patients receiving intrathecal hydromorphone. DESIGN: A retrospective review was conducted of all patients receiving intrathecal hydromorphone monotherapy in two large pain specialty practices in the Pacific Northwest. All data collected within 30 days of the patient's 3-month, 6-month, and 12-month anniversary of implant were analyzed. PATIENTS: Twenty-four patients with noncancer-related chronic pain were included in the study. Thirteen patients had eligible pain data at 1 month, 10 patients had pain data at 3 months and seven patients had pain data available at 12 months after initiation of intrathecal hydromorphone. RESULTS: Average pain scores decreased significantly (P = 0.03). Side-effect and pain-interference scores remained essentially unchanged in this small sample of patients.

Care and management of intrathecal and epidural catheters.

Epidural and intrathecal catheters have increasingly become a part of acute and chronic pain management over the past 25 years. Externalized systems include temporary, permanent exteriorized, and permanent port systems for use over weeks to months of expected therapy. Implanted, completely internalized systems are available for conditions expected to require many months or years of therapy. Expert care includes routine management as well as advanced troubleshooting. Prevention of infection is a key priority for nurses managing these devices.