PAIN MANAGEMENT

Report
Matching Interventions to
Barriers in Pain Management
Ruth Cornish
Program Manager
National Institute of Clinical Studies
Role:
To improve health care by helping
close important gaps between
best available evidence and
current clinical practice
What
we
know
What
we
do
Acknowledgements
• Prof. Sanchia Aranda
• NICS advisors
• Deb Gordon & June Dahl
(Wisconsin pain group)
• Pilot hospital teams
Pilot hospitals
Royal Brisbane
Charles
Gairdner
Royal Perth
Newcastle Mater
Flinders
Royal Adelaide
Westmead
Peter Mac
Background
www.nicsl.com.au
Aims
1. To improve the identification of patients
with pain
2. To improve the day-to-day management
of pain for patients with cancer
3. To integrate effective cancer pain
management into the core business of
hospitals
Barriers - Institutional
• Lack of institutional commitment
• Poor visibility of the problem
• Professional territorial issues
• Unclear lines of responsibility
• Lack of practical tools & policies
Barriers – Clinicians
•
•
•
•
•
Attitudes & beliefs of staff
No routine pain assessment
Under-estimation of patients’ pain
Analgesia misconceptions
Prescribing & administration
inconsistencies
• Inadequate knowledge and
education
Barriers – Patients
•
•
•
•
•
•
Inevitability of pain
Stoicism
Analgesia fears & misconceptions
Being a “good” patient
Distracting from treatment
Trade-offs: analgesics & side effects
Where to start?
Matching
interventions to barriers
Generic Principle
• Lack of knowledge
– Educational courses
– Evidence based
guidelines
– Decision aids
• Beliefs/Attitudes
– Peer influence
– Opinion leaders
• Lack of motivation
– Incentives / sanctions
• Perception-reality
mismatch
– Audit & feedback
– Reminders
• Systems of care
– Process redesign
Institutional
• Lack of institutional commitment
– Executive champions
– Peer hospitals?
• Poor visibility of the problem
– Audit & feedback to executive
– We have a problem!
Institutional
• Professional territorial issues
– get everyone involved
– multiple champions
eg.
Disciplines
Nursing
Medicine
Pharmacy
Quality/safety
Departments
Pain
Palliative care
Medical/Surgical
Quality/safety
Clinical
• Inadequate knowledge, education
– needs analyses useful
– don’t expect attendance at special
meetings
– use existing meetings opportunistically
– include in orientation, rounds, intranet
– nursing competency standards
Clinical
• Attitudes and beliefs
–Opinion leaders
–Clinical champions
–Peers
Clinical
• No routine assessment
–documented pain scores on vital
sign chart
–reminders
–audit & feedback essential
Clinical
• Prescribing inconsistencies
–guidelines and decision aids at
point of prescribing
–equi-analgesia cards
–standardised prescribing
Patient
• Inevitability of pain; stoicism; being
a "good" patient
– "your pain is important to us"
– organisation mission statement
– hospital admission/discharge information
includes pain management
– ward posters
Patient
• Distracting from treatment
–"your pain is important to us"
–involve patient in their own pain
management
–prompts to discussion
Patient
• Analgesia fears, misconceptions
(particularly addiction)
–starting morphine is a "threatening
procedure" for cancer patients
–information for patients & families
Matching
interventions to barriers
Begins with a sound
analysis of barriers

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