development & implementation of “sliding scale” pain protocols jayne pawasauskas, pharmd,...
TRANSCRIPT
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Development & Implementation of
“Sliding Scale”Pain Protocols
Jayne Pawasauskas, PharmD, BCPSClinical Professor
URI College of Pharmacy&
Clinical Pharmacy Specialist – Pain Management Kent Hospital
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Objectives for Today
To describe the development and implementation of protocols developed to manage acute pain for patients admitted to a medical service
After participating in this presentation, you should be able to: Discuss the rationale for implementation of
acute pain protocols that can be effective for both opioid naïve and varying degrees of opioid tolerant patients
Demonstrate how use of acute pain protocols facilitates compliance with Joint Commission standards and regulations
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Drivers for Change Joint Commission
Sentinel Event Alert Prevention of errors Prevention of duplicate orders
Encourage use of Multimodal Approach (MMA) Limit occurrence of opioid-related ADEs
(ORADEs) Our hospital specifics/background
sometimes poor opioid conversions during TOC Provide consistent analgesia Wish list: improve patient satisfaction (HCAHPS
scores)
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% C
hange
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Background Information on the Protocols
Created from analysis of inpatient opioid usage/requirements in non-surgical patients Total amount of opioid used by patients in a
variety of medical states on first day of admission, then followed for 10 days or until discharge.
Sample patients did not require naloxone at any point during hospitalization
Sample deemed to have safe and effective use of opioids
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Surveillance Data
=> High Dose
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The 6 Acute Pain Protocols
Breakpoints were set to distinguish 3 groups of patients: Low dose (0-50 MED per day or opioid naïve) Medium dose (51 – 100 MED per day)
Patient continues on home med of long-acting analgesic and uses this protocol to manage breakthrough pain
High dose (>100 MED per day) Patient continues on home med of long-acting analgesic and
uses this protocol to manage breakthrough pain
For each of these dose ranges, there is a regular/normal PowerPlan, and one for NPO patients
Each protocol contains 3 steps of analgesia (and medications): mild (any pain >0), moderate (pain 4-7), and severe (pain 8-10)
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LowDose Protocol
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High Dose Protocol
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High Dose NPO
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Link to Global RPh
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Preliminary Data
Initial 90 days after implementation
Plan # patients (%)
Low dose 58 (84.1%)
Low dose NPO 5 (7.3%)
Medium dose 4 (5.8%)*
Medium dose NPO
1 (1.4%)
High dose 1 (1.4%)
High dose NPO 0
* One occurrence of medium dose protocol ordered on an opioid-naïve patient
No other overt errors encountered with selection of appropriate protocol forIndividual patient
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Indications
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Pharmacist interventions
Documentation of pharmacist interventions for 13% of patients Therapeutic duplication Tramadol issues (additive seizure risks with
other meds on profile, fall risk) Clarify home med vs. protocol med Drug Allergy General questions
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Subgroup Analysis
Exlusion criteria Patient received less than 2 doses of pain
protocol med/24 hr Patient admitted to ICU at any time during
hospitalization Surgical patient/post-op Excluded nursing unit (4W or 2N)
N=26 Representing 12 different hospitalist
prescribers
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Efficacysubgroup analysis of patients meeting study inclusion criteria (n=26)*
Baseline pain score Average = 7.13 Median = 7
17% were opioid tolerant Time to analgesia
Average = 7.5 hr Median = 4.35 hr
* 2 patients excluded from analgesia analyses due to problems with documentation of pain scores
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Safety Use of naloxone 0 GI ADRs
3 patients had documented episodes of diarrhea No additional treatments needed
C.diff 2 patients tested
One negative – admitted for Abd. Pain/diarrhea prior to use of protocols
One positive – admitted with h/o C.diff
Constipation 1 patient had documented constipation
Administered enema; addition of senna/docusate BID, bisacodyl PR prn
Nausea/Vomiting 6/5 patients – received additional ondansetron or
prochlorperazine Most patients had admitting diagnosis contributing to N/V
(i.e. EtOH withdrawal, n/v, infections, cancer)
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Potential Pitfalls….
Correlation of breakthrough pain medication to numeric pain scores ?indications becoming too specific?
Incorrect use could create duplications PowerPlan on profile + additional
opioids ordered Pharmacists must be very careful when
reviewing new orders for analgesics
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Questions?