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SAFE USE OF OPIOIDS NATIONAL COLLABORATIVE LEARNING SESSION ZERO

Judy Leader Nurse Practitioner Pain Management MidCentral Health 2014

OPIOID ARE INDICATED FOR…

MCH PAIN MANAGEMENT REVIEW 1999 Develop a multidisciplinary team to promote best

practice in pain management Staff Pain Management Knowledge and Attitude

Study Patient Pain Management Satisfaction Survey Audits of Clinical Practice Audits of Emergency Dept Admission Trends Introduction of Pain as Fifth Vital Sign

THE TEAM Clinical Director-Rehab Clinical Nurse Specialist-Child Health Nurse Clinician-Acute Pain Service Clinical Director-Hospice Clinical Nurse Specialist-Palliative Care Clinical Coordinator-After hours Clinical Pharmacist Complementary Health Midwifery Physiotherapy Clinical Nurse Specialist-Elder Health Alcohol and Drug Service Occupational Health Professional Pharmacy Advisor Orthopedics General Practice

MISSION The MidCentral Health Multidisciplinary Pain Management

Team promotes safe, timely and effective relief of pain and suffering for all patients by advancing pain

management skills, knowledge and attitudes within our community.

AGREED VALUES

Patient first Equity Quality

KEY GOALS

Advance health Build capacity

Track performance Measure outcomes

BASELINE DATA

20-25% of admissions identify pain as primary complaint.

88.7 % of patients stated they experienced pain.

Only 7.2% of patients had documented evidence of pain assessment.

Staff knowledge deficits in assessment, addiction, pharmacology and physiology/pathophysiology of pain.

No common language.

LANGUAGE UTILISED TO DOCUMENT PATIENT’S LEVEL OF COMFORT

Appears comfortable Regular analgesia given Nil complaints of discomfort c/o pain tramadol/panadol given as charted Given regular pain relief Complaining of pain +++ Analgesia as charted with effect No mention of pain Codeine, morphine, panadol given

KEY STRATEGIES; STANDARDISE AND PROMOTE PAIN ASSESSMENT

PAIN ASSESSMENT AT MCH Cause and physiological

response Location(s) Intensity (at rest and on

movement) Quality Onset and duration Precipitating factors Modifying factors Psychological response Behavioral response Re-assessment

MIDCENTRAL HEALTH PAIN ASSESSMENT AUDITS 2001-2003

020406080

100

Cause

Locatio

n

Inte

nsity

Qualit

y

Onse

t/Dura

tion

Precipita

ting F

x

Modify

ing F

x

Psych

ologi

cal R

x

Behavioura

l Rx

Rea

sses

smen

t

Recommended components of pain assessment

Percentage of clinicians

able to identify

component

2001

2002

2003

IMPLEMENT PAIN AS THE 5TH VITAL SIGN

Toolkit for Implementation

FIFTH VITAL SIGN AUDIT-THE PROCESS

10 sets of clinical notes randomly selected from 11 clinical areas 2002-2014, (sample 110 pts).

MidCentral Health Nursing Assessment form. MidCentral Health Observation chart. Evidence of pain assessment in previous 24hrs

clinical notes, all disciplines. Evidence of analgesia administered (treatment

chart). Evidence of evaluation of analgesia’s efficacy.

PAIN ASSESSMENT-CLINICAL

0

20

40

60

80

100

2002 2006

DEVELOP/ PROMOTE PHARMACOLOGICAL PAIN MANAGEMENT GUIDELINES

PLAN, FACILITATE AND EVALUATE MULTIDISCIPLINARY PAIN MANAGEMENT EDUCATION

Senior Clinicians/Management Pain Management workshops.

Monthly multidisciplinary forums. Annual Pain Management Awareness Week New Zealand Pain Society. Australian National

Institute for Clinical Studies, National Health Committee.

DEVELOP PAIN MANAGEMENT PUBLIC AWARENESS INITIATIVES

Chronic Pain Support Foundation. Pain Management Awareness Week. Newspaper articles, public speaking. Liaison with local providers of pain management

services.

DEVELOP AGREED STANDARDS OF PAIN MANAGEMENT Recognise the patients rights to appropriate assessment and

management of their pain. Determine and ensure staff competency in pain assessment

and management, and address pain management in the orientation of all new staff.

Assess existence, nature, intensity of pain in all patients. Record results of pain assessment in a way that facilitates

regular reassessment and follow up. Establish policies and procedures supporting appropriate

prescription or ordering of pain medications. Monitor patients continuously post procedure for pain

intensity and quality, and response to treatments. Educate patients and their families about effective pain

management practices. Address patient needs for pain management in the discharge

planning process. Collect data to monitor the appropriateness and effectiveness

of pain management. JACHO 1999

EXPERIENCE OF PAIN

0

20

40

60

80

100

pts pain

2002

2005

PAIN MANAGEMENT

0

20

40

60

80

100

want/need Tx receive Tx

2002

2005

PATIENT SATISFACTION PAIN MANAGEMENT 02-05

020406080

100

NurseTx Pain

02

NurseTx Pain

05

DoctorsTx Pain

02

DoctorsTx Pain

05

OverallSatis 02

OverallSatis 05

DOCUMENTATION OF PAIN ASSESSMENT PRIOR TO AND FOLLOWING ANALGESIC INTERVENTION

IS VITAL TO ENSURE EFFECTIVE HEALTH OUTCOMES

0

10

20

30

40

50

60

70

80

90

100

Ward A Ward B Ward C Ward D Ward E Ward F Ward G Ward H Ward I Ward J Ward K

Per

cent

age

com

plet

e

Clinical area

Fifth Vital Sign; Assessment all areas, 2012-2014

201220132014

0

10

20

30

40

50

60

70

80

90

100

Ward A Ward B Ward C Ward D Ward E Ward F Ward G Ward H Ward I Ward J Ward K

Per

cent

age

com

plet

e

Clinical area

Fifth Vital Sign; Observation chart all areas 2012-2014

201220132014

0

10

20

30

40

50

60

70

80

90

100

Ward A Ward B Ward C Ward D Ward E Ward F Ward G Ward H Ward I Ward J Ward K

Per

cent

age

com

plet

e

Clinical area

Fifth Vital Sign; Pain as focus of care, 2012-2014

201220132014

The aim is to have both bars matching

0

10

20

30

40

50

60

70

80

90

100

Ward 23 Ward 24 Ward 25 Ward 26 Ward 27 Ward 28 Ward 29 Star 1 Star 2 Ch Ward WSU

Per

cent

age

com

plet

e

Clinical area

Fifth Vital Sign; Intervention/evaluation all areas 2014

interventevaluation

(PGY1 HOUSE SURGEONS-2013)

What is the first line strong oral opioid? 70% Oxycontin/norm Is laxative and antiemetic routinely prescribed? 60% Yes Is Oxycontin/norm stronger, weaker, same strength as

oral morphine? 80% wrong Indications for Oxycontin/norm use? 80% did not know Do you limit amount patient discharged on (excluding

palliative care patients) ? 80% Yes Do you talk to GP and have discharge plan? 80% No

THE MIDCENTRAL HEALTH APPETITE/NAUSEA SCALE PROJECT 2012

It’s not about the number!

A COMPLAINT REGARDING THE FEEDING OF A PATIENT INITIATED A

QUALITY IMPROVEMENT PROJECT THROUGH THE MIDCENTRAL HEALTH NURSING CLINICAL

PRACTICE ACTION GROUP (CPAG).

THE NURSING PROCESS WAS UTILIZED AS A FRAMEWORK IN THIS PROJECT

STEP 1. ASSESS THE SITUATION PATIENTS IN HOSPITAL LOSE WEIGHT. NURSES DO NOT UTILISE A STANDARDISED APPROACH TO DISCUSS, DOCUMENT AND MONITOR APPETITE OR NAUSEA.

Data sourced to inform our critical thinking: •Documentation audit •Patient survey •Literature review •Working groups •Assessment and Reliability Taskforce data •Focus groups •Staff feedback

PATIENTS WERE INTERVIEWED. THEIR DOCUMENTATION WAS ALSO REVIEWED

Patients complained of •Anticipatory nausea •Intermittent nausea •Constant nausea •Retching •Vomiting •No appetite

Effect on patients appetite •No effect on appetite •Patient eating with nausea •Patient drinking with nausea •Patient eating and drinking •No appetite unrelated to nausea

None of these patients had regular antiemetic charted PRN medications prescribed included Metocloprimide 10mg,

Ondansetron 4-8mg, Domperidone 10mg, Cyclizine, 50mg none were administered regularly.

SUMMARY-APPETITE &NAUSEA AUDIT JUNE 2011

Multiple factors influence appetite

Food (smells, presentation) Mood Lack of exercise Lack of fresh air Constipation Medications Treatments (e.g. radiotherapy,

surgery) Failure to administer anti-emetics as

prescribed/required Dry mouth/ sore mouth

Multiple factors influence nausea

May be anticipatory, intermittent, constant

May be associated with eating, drinking, movement, medications and anxiety

May or may not be associated with retching or vomiting

Tendency towards PRN rather than regular prescription/administration of anti emetic

Step 2.Diagnosis: Naming the problem •Our current observation form did not support documentation •Yes/no response provided little useful data to monitor common symptom progression (Feedback to working group/CPAG)

Step 3. Planning:

What are we going to do and how? We needed to identify a tool which will improve the assessment and management of our patients appetite and nausea

AIM OF THE TOOL: TO PROVIDE A COMMON LANGUAGE TO DISCUSS NAUSEA AND APPETITE.

AN ASSESSMENT SCALE WAS DEVELOPED AND PILOTED BY STAFF IN WARDS 23, ONCOLOGY AND 24, ORTHOPAEDICS FOCUS GROUPS FACILITATED, FEEDBACK FORMS COMPLETED AND SUMMARIZED TOOL AMENDED FURTHER TO INCORPORATE NURSING FEED-BACK REVISED TOOL PILOTED & AGAIN FEEDBACK SOUGHT AND COLLATED

STEP 4. IMPLEMENTATION: MAKING IT HAPPEN MCH OBSERVATION CHART HAS BEEN REDESIGNED. A SCORE DEVELOPED BY MCH NURSES IS NOW REQUIRED WHEN DOCUMENTING APPETITE & NAUSEA.

The MidCentral Health Appetite and Nausea scale

ID cards have been developed and are available from materials management to promote the assessment of appetite and nausea (Order nos 740116)

THE PATIENT IS NOT

REQUIRED TO PICK A NUMBER HOWEVER THE PATIENTS REPORT WILL

INFORM THE SCORE

A poster has been developed to assist the marketing and promotion of this initiative.

It is available to download from the nursing portal, follow CPAG link

THE SCALE IS INTENDED TO IMPROVE COMMUNICATION WHICH WILL

INFORM ASSESSMENT, MONITORING AND EVALUATION OF APPETITE AND

NAUSEA OVER TIME.

POTENTIAL CONTRIBUTING FACTORS TO CONSIDER… •Chemicals-drugs such as opioids, steriods, antibiotics •Treatments-radiation therapy, chemotherapy •Biochemical imbalance-Hypercalcemia, hyponatremia uraemia, endocrine imbalance •Toxins-infection, ischaemic bowel •GI tract disturbance-ileus, constipation, obstruction •Psychological factors-fear, anxiety, pain Chose a case study from the following and discuss with colleagues

QUESTIONS TO CONSIDER.. •Based on your assessment what could be contributing to your patients appetite/nausea? •What is your patients appetite/nausea score? •What interventions will you consider & why? •How will you evaluate the efficacy of these interventions and record your findings? •Who could you ask for help?

CASE STUDY 1

68 year old male returned from OT last night following a total hip replacement with PCA in situ. At 7.30 am the following morning the patient rates his pain score at 5/10 and states he has no appetite and does not feel like eating breakfast. No nausea reported.

CASE STUDY 2

24 year old female recently diagnosed with breast cancer. Presents with persistent nausea. Has not eaten for three days. Has tried Metoclopramide 10mg with no effect. No complaints of pain.

FEEDBACK FROM NURSES INVOLVED IN PILOT

Ensures that I monitor patients’ eating habits

Engages conversation around appetite Allows for measurement of patients

perception of nausea/appetite Good for documentation as focus charting Focus awareness on lack of appetite Makes you more aware Picks up patients with poor appetite

STEP 5. EVALUATION: HAS OUR PRACTICE CHANGED? FURTHER DATA SOURCED TO MEASURE PROGRESS AGAINST BASELINE. REPORT TO STAKEHOLDERS REPEAT PROCESS AS NECESSARY TO ENSURE CONTINUOUS QUALITY CYCLE MAINTAINED

Thanks to those who participated in this project

Staff of Ward 23 & 24

OTHER MCH OPIOID RELATED INITIATIVES Integration of e-pharmacy Integration of Safer Sleep Review of Acute Pain Service documentation NP outreach model of care

PAIN & DISTRESS