capa midwest pain society oct 2015.pptx...

10/26/2015

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Debra J. Drew, MS, ACNS-BC, RN-BC, AP-PMN

Implementation of the

CAPA©(Clinically Aligned Pain

Assessment) Tool:

Pain is More than Just a Number©

Conflict of Interest Disclosure

• Author’s Conflict of

Interest

No Conflicts of Interest

Objectives

Learners will be able to:

1. Discuss the concept of pain assessment as a

social transaction between patient and

clinician.

2. Summarize the outcomes of University of

Minnesota Health’s implementation of CAPA©.

3. Describe the lessons learned from

implementing a complex and culture-changing

project.

Impetus for Change at University of

Minnesota Medical Center2012

• Low patient pain satisfaction scores (HCAPH)

• Anticipation of effect of Centers for Medicare and Medicaid’s Value-Based Purchasing plan

– Reimbursement based in part on satisfaction with care.

• State of Minnesota, an average of 70% of patients reported satisfaction with pain management scores (MDH, 2014)

• Staff dissatisfied with current numeric pain scale

Are Pain Ratings Irrelevant?

• Noted that fellow pain and palliative care colleagues didn’t always ask about pain intensity using the numeric scale

• In 2015, Short Survey of APS members, N=41

– Pain clinicians do not routinely use pain intensity ratings as part of the pain assessment during clinical practice.

Backonja M & Farrar JT. (2015) Are pain ratings irrelevant? Pain Medicine, 16(7): 1247-1250.

Tide of Thought Shifting

• Reliance on unidimensional scales to guide treatment have been linked to serious adverse events: Increased incidence of opioid over-sedation from 11-24.5/1,000,000 inpatient hospital days.

• Documentation of pain is treated as a regulatory nuisance and clinical decision making is not linked to assessment data.

• Pain is complex and assessment tools need to reflect that complexity, yet be pragmatic in clinical use.

• Pain assessment is a complex communication process between the patient and clinician.

Gordon, DB. Acute pain assessment tools: let us move beyond simple pain ratings. Current Opinion in Anaesthesiology, October 2015, Volume 28 (5), 565-569.

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Debate on Self-Report as Gold

Standard in Pediatric Pain IntensityPro:

• Pain is subjective and can only be assessed via self-report

• Guides appropriate treatments.

Con:

• Reliance on self-reported pain scores oversimplify the pain experience,

• Yield only marginal information on which to base clinical decisions,

• Potentially place children at significant risk for adverse events.

Twycross A, Voepel-Lewis T, Vincent C, Franck LS and von Baeyer CL (2015), A debate on the proposition that self-report is the gold standard in assessment of pediatric pain intensity. Clinical Journal of Pain,31(8),707-12.

Pain Assessment as a Social TransactionSchiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676.

• Problem with self-report using a one-dimensional

scale

– Pain is a multi-dimensional complex experience

– Numeric scale difficult for some to use

– Requires linguistic and social skills: problematic

with some of most vulnerable populations

– Patients modulate pain behaviors and self-report

based on their perception of what’s in their best

interest

Patients Modulate Pain ReportsPain Assessment as a Social Transaction

Beyond the “Gold Standard”

• Self-report= gold standard

• Major disconnect between what is advocated and what clinicians actually do

• “Pain is what the patient says it is” acknowledges subjectivity of pain, but ignores complex patient/clinician relationship

• “Pain as 5th Vital Sign” highlights significance of pain, but can be mechanistic

Schiavenato, M & Craig KD. (2010). Pain assessment as a social transaction beyond the “Gold Standard.” Clinical Journal of Pain, 26(8): 667-676.

Pain Assessment as a Social Transaction Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676.

Biological

Sociocultural

Developmental/Psychological

Experience/Empathy

Contextual/Situational

Experience

(Patient Meaning)

Expression Assessment

Judgment

(Clinician Meaning)

Contributing Factors

Assessment Process Patient Clinician

Pain

StimulusInter-

vention

Examples of Contributing Factors in

Pain AssessmentBiologic Sociocultural Developmental-

Psychological

Experience/

Empathy

Contextual/

Situational

Patient Disease,

clinical

condition,

drug

influences

Ethnicity, sex,

access to

healthcare,

cultural

origin

Age, stress, drug

addiction,

interpersonal

skills, fear

Previous

experience

of pain

Language,

fear/stress,

Similarity to

clinician,

socioeconomic

status

Clinician Biologic

disposition,

stress

reactivity

Pt.

preferences

or biases,

age, sex,

education,

ethnic

background

Views on pain,

trust/suspicion,

Interpersonal

skills, critical

evaluation of

pain report

Knowledge,

clinical

competence,

empathy,

institutional

insensitivity

Workload,

interdisciplinary

communication,

facility resources

Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676

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Summary of the Social Transaction

of Pain Assessment

Pain assessment best described as a dynamic process, a transaction:

• Intersubjective exchange of meaning between patient and clinician

• Verbal and nonverbal interaction between patient and clinician is modified by the physiologic and social context

• Process dependent on internal/external factors to both parties and environment

News of a New Tool

University of Utah – 2012 Pilot Project

• CAPA© developed to replace conventional numeric rating scale (NRS; 0-10 scale)

• Press Ganey© scores increased from 18th to 95th percentile

• 55% patients preferred CAPA ©

• Nurses preferred CAPA © 3:1 over NRS

From, Donaldson & Chapman, 2013.

Clinically Aligned Pain Assessment (CAPA)

“Pain is More Than Just a Number” ©

• Evaluates

– intensity of pain

– effect of pain on functionality

– effect of pain on sleep

– efficacy of therapy

– progress toward comfort

• Engages patient and clinician in a brief conversation about pain resulting in coded evaluation


CAPA© Tool (modified; original in blue)

The conversation leads to documentation- not the other way around.

Question Response

Comfort •Intolerable

•Tolerable with discomfort

•Comfortably manageable

•Negligible pain

Change in Pain •Getting worse

•About the same

•Getting better

Pain Control •Inadequate pain control Inadequate pain control

•Partially effective Effective, just about right

•Fully effective Would like to reduce medication (why?)

Functioning •Can’t do anything because of pain

•Pain keeps me from doing most of what I need to do

•Can do most things, but pain gets in the way of some

•Can do everything I need to

Sleep •Awake with pain most of night

•Awake with occasional pain

•Normal Sleep


Change or Transformation?

Change is the “fixing” of past to future:

� Better, cheaper, faster, leaner, etc.

Transformation is the job of leaders:

� Building a vision

� Start with the future and

work back

� Help people fall in love with the future

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Transformation

The butterfly is NOT

a better, faster

caterpillar.

It is a NEW

system.

Building an Institutional Commitment

to Pain Management

Gordon DB, Dahl JL, Stevenson KK (1996) and (2000)

• A resource manual that provided a framework to

promote practice changes that would improve

quality of pain management for all patients.

Steps of Implementation

1. Define the scope and team

2. Identify and manage the risks

3. Breakdown the work

4. Schedule the work

5. Communicate

6. Measure progress

From, Verzuh (2008).

University of Minnesota Medical Center

– A River Runs Through It

1932 licensed beds

885 staffed beds

1. Defining the scope and team – Phase 1

Scope (Adult Inpatient)

• Medical Units

• Surgical Units

• Behavioral Units

• Obstetrics Units

• Acute Rehabilitation

• Transitional Care

• Emergency Departments

• Perioperative Services

Team

• Champion: Chief Nursing Executive

• Quality and Performance Improvement Consultants

• Data Analysts

• Electronic Health Record Consultant

• Nurse Managers

• Staff Nurse Leaders

• Nurse Educators

• Communications Department


�Infusion Centers

�Clinics

�Procedural Areas

• Scope (Adult Outpatient)

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�Process begins with validation of tool in pediatric

population

• Scope (Pediatrics)

2. Identify and manage the risks

Potential failures/risks

• Failure to gain cooperation

of nurses and physicians

• Concerns of researchers

using the numeric scale

• Failure to increase patient

satisfaction or improve pain

management

Managing Risks

• Buy-in from key leaders

• Contacted IRB to notify

researchers of change

• Weekly monitoring of

process with monthly

monitoring of outcomes

3 & 4. Breakdown and schedule the work

Aug ‘13 Sept Oct Nov Dec Jan ‘14 Feb Mar April May June July

Take to Leadership groups

Develop content of

presentations

Establish plan for data

collection

Build doc and reports to

support

Form House w ide Group and

unit based group

Engage Stakeholders

Assess current state of

practice, research (

Communicate/educate all

disciplines

Implement: Inpatient

Monitor, evaluate, tweak,

sustain

Implement: Outpatient

,

Month

Determine & Establish

Accountability desired

outcomes, Structure /roles

at all levels

5. Communicate

• Who

– Special interest groups: Nurse Managers/Directors, nursing staff, physician groups, APRNs, nursing practice committees, social workers, therapists, champions

• When

– Before, frequently throughout

• What

– Purpose, expected behaviors, expected outcomes, patient/family feedback, process and outcome measures

• How

– Via meetings, newsletters, intranet, patient stories, staff stories, e-mail

6. Measure progress

• Process measures:

– Weekly compliance report per unit

– Identification of individuals still using numeric

scale: can be coached and counseled

• Outcome measures:

– Monthly CAPA© outcomes

– Press Ganey© pain satisfaction scores

Objective 2: Summarize the outcomes of

University of Minnesota Health’s

implementation of CAPA©.

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Electronic Data AbstractionProcess Measures

CAPA © Compliance

Outcome Measures - CAPA©

6.41%

27.01%

22.67% 22.67%21.82%

18.96%

16.67%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

January February March April May June July

Effectiveness of Pain Control (by Month)

Outcome Measures - CAPA©

50.50%

51.48%50.95% 50.95%

51.23%50.75%

51.04%

44.00%

46.00%

48.00%

50.00%

52.00%

54.00%

56.00%

58.00%

60.00%

January February March April May June July

Degree of Comfort by Month

Outcome Measures – Press Ganey ©

• Overall Pain Management

– Staff Did Everything They Could to Help With Pain

– Pain Well Controlled

Press Ganey© - Overall Pain Management

(by month)

50

55

60

65

70

75

80

% Average 3 STD 2 STD

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Press Ganey© - Staff Did Everything to Control Pain

(by Month)

60

65

70

75

80

85

90

% Average 3 STD 2 STD -2 STDEV -3 STD

Press Ganey© Scores Pre and Post

CAPA Implementation by Quarter

Anecdotes

Patient perspective: “Makes me feel like the nurses care more about my pain.”

Nurses perspective:

• “It makes sense.”

• Many had been frustrated by numeric scale and liked the change. “I hated that 0-10 scale.”

Nurse Survey1 med-surg unit (N=21, 67% return)

80% satisfied or very satisfied with implementation

80% felt communication with patients improved with CAPA ©

71% satisfied with rationale for change

66% preferred CAPA© over NRS

47% believe patients have somewhat better pain

management with CAPA ©

Thanks to Emily Drobinski, Carrie Hallstrom, Kelly Pavlicek, Mary Sylvestre,

Heather White , Clare Zielinski: Unit 8A, UMMC

Objective 3

• Describe the lessons learned from

implementing a complex and culture-changing

project.

Learnings

• Numeric scale embedded in many different

places in EHR.

• Pain assessment by many different people

– Students, faculty, therapists, technicians, etc.

• Some staff are not skilled at “talking with”

patients; this presented a challenge.

• Some people resist change!

• Staff can be the biggest champions!

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Unexpected Occurrences Information about the CAPA© tool

• Tool not validated according to standards of psychometrics.

• Study by Drew, Hagstrom & O’Connor-Von (unpublished) found no correlation between numerical scores and concurrent CAPA comfort domain. N=30, repeated measures

Found that can’t compare quantitative data to qualitative data.

• Donaldson (2014) recommends nonparametric approach in research design

Additional Learnings

• Staff need to recognize this as culture change

versus a “project”

• Glitches happen in spite of best planning

• Ripple effects of change occur

• Barriers along the way: people, processes,

tools

• Facilitators: people, processes, and tools

Implications for Outpatient Settings

• Pain screening question in clinics = numeric

intensity score gathered by non-professional

– Didn’t cue professional about patient’s pain status

or concerns (documentation not readily visible)

– Didn’t meet the intent of TJC standard to assess

patient’s pain in outpatient setting

Recommendations

for Outpatient Settings

• Delete numeric pain scale from intake data.

• Ask screening question: “Do you have pain that needs to be addressed at this appointment?”

• Answer flows to Vital Signs flow sheet that is reviewed by RN and provider

• CAPA available on flow sheet for charting pain assessment

• Dot phrase available for easy charting in narrative note if preferred by provider.

Recommendations in Process

• “Make it hard to do the wrong thing, and easy to do the right thing.” Joanne Disch, PhD, RN

• Educate via presentations, electronic learning, written materials, interpersonal meetings. Repeat, repeat again….

• Utilize electronic medical record to match work flow

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Recommendations

• Speak to fears and concerns:

– Fear of making an “assessment”: some nurses are

more comfortable with patient’s statement of a

number than trying to interpret interaction

– MDs fear that they won’t know how to respond

when nurse calls with CAPA information

• Engage executive leadership as necessary

A Tale of Two Emergency Departments

West Bank ED 2nd Quarter

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3/24 3/31 4/7 4/14 4/21 4/28 5/5 5/12 5/19 5/26 6/2 6/9 6/16 6/23

3/24 3/31 4/7 4/14 4/21 4/28 5/5 5/12 5/19 5/26 6/2 6/9 6/16 6/23

Both CAPA and Numeric 12% 7% 9% 7% 7% 5% 5% 2% 2% 2% 3% 1% 1% 0%

CAPA Only 84% 90% 87% 91% 90% 94% 94% 97% 98% 97% 96% 99% 98% 100%

Numeric Only 4% 3% 3% 2% 3% 1% 2% 0% 0% 2% 1% 0% 1% 0%

Both CAPA and Numeric

CAPA Only

Numeric Only

East Bank ED 2nd Quarter

VP Letter to Staff

Summary

• Pain assessment is not merely the subjective

statement of the patient, no more than it is the

sole objective decision of the clinician.

• Rather, pain assessment is the intersubjective

exchange of meaning between the patient and

clinician.

• It is a process, which is ongoing and dependent

on both the internal and external factors inherent

to both the parties and their environment.

Summary

• CAPA© is an expanded way to assess pain using a transactional conversation between patient and clinician.

• Findings: Changing from the numeric scale to the CAPA© tool is a cultural change for staff and patients.

• Next steps at M Health include:

– Expansion to most care settings within hospital system.

– Validation of tool in adolescents

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The Impact

“Nobody makes a greater

mistake than he who

did nothing because he

could do only a little.”

Edmund Burke

The Power of Many Drops

Questions ? References

Donaldson, G., & Chapman, C.R. (2013). Pain management is more

than just a number. University of Utah Health/Department of

Anesthesiology. Salt Lake City, Utah: Department of Anesthesiology.

Schiavenato, M., & Craig, K.D. (2010). Pain assessment as a social

transaction: Beyond the gold standard. The Clinical Journal of Pain,

26(8), 667-676.

University of Utah Health Care. (n.d.). Giving patients a voice, not a

number. Retrieved from:

http://healthcare.utah.edu/nursinginnovation/10ideas/two.php

Verzuh, E. (2008). Fast forward MBA in project management (3rd ed.).

Hoboken, NJ: John Wiley & Sons, Inc.

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