Improving Pain Management in Nursing Homes

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Improving Pain Management in Nursing Homes

• David R. Gifford MD MPH
• Joan Teno MD
• Center for Gerontology and Health Care Research,
  Brown Medical School
• Rhode Island Quality Partners

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Nursing homes

• On a given day, 1.5 million Americans are in a
  nursing home.
• Nearly one in two persons who live to their 80s
  will spend time in a nursing home prior to death.
  
• Federal policy in the 1980s have resulted in
  shorter hospitalization and increased use of
  nursing homes

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Nursing Homes (2)

• By 2020, it has been estimated by Brock and Foley
  that 40 of Americans will die in nursing homes.
• Already, some states have nearly 40 of Americans
  dying in nursing homes

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Yet, Nursing Home are Increasing the Site of Death
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Nursing homes

• Many NH provide compassionate, competent, and
  coordinated medical care. They are the final
  home
• Yet there are important opportunities to improve

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Pain

• As high as 83 of NH resident experience pain
  that impairs mobility, causes depression, and
  diminishes quality of life.
• Recent research has found that pain is often
  unrecognized and not treated by health care
  providers

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JAMA Research Study

• Examines pain management in all US Nursing homes
  in 1999 using the federally required, Minimum
  Data Set that collects information on the
  frequency (daily or less than daily) and severity
  of pain (none, mild, moderate or excruciating) at
  admission and quarterly.

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Persistent Pain JAMA 4/25/01

• This study found that 41.5 of persons who had
  pain at the first assessment within 60 days of
  April, 1999 had either moderate daily pain or
  excruciating level of pain at the next
  assessment, completed 60-180 days later.
• Of those persons with two MDS assessments, ONE in
  SEVEN were in persistent severe pain.

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Persistent Pain JAMA 4/25/01

• The Rate of persistent pain varied between 37.7
  and 49.5. Yet, the majority of states were near
  40. (See next figure)

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Why is it Important to Focus on Pain?

• Pain is a symptom most expected and most feared
  by dying patients.
• Unrelieved pain can have enormous physiological
  and psychological effects on the patient and
  their loved ones.
• Pain negatively affects the quality of life by
  impairing daily functions, social relationships,
  sleep and/or self worth.

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Project Goals

• Measure improve pain management in nursing
  homes
• assessing pain
• using pain intensity scale
• using non-pharmacologic treatments for pain
• using regularly scheduled pain medications (i.e.
  decrease PRN pain meds for residents in daily
  pain)

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Project Design (Overview)

• Recruited 21 nursing homes (NH)
• Formed teams in each NH
• Measured current practice
• Identified areas needing improvement
• Applied CQI principles (e.g. PDSA cycles)
• Remeasured practice

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Role of Brown and RIQP

• Clinical information
• Pain resource guide
• pain rating scales
• medical literature
• Seminars
• pain management
• CQI principles

• Data Collection
• medical record abstraction form
• data analysis
• Technical support
• Nurse specialist
• on sight visits
• telephone contact
• CQI team training

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Measuring practice

• Nursing homes collected their own data
• selected 20 residents with pain using MDS
• 10 without dementia
• 10 with dementia
• Used 2 page data collection form
• pain intensity frequency
• how pain is assessed
• use of scales to rate pain
• use of pain medications
• use of non-pharmacologic approaches

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Formation of CQI teams

• Interdisciplinary teams
• unit level
• Unit manager
• Nursing CNAs
• Met frequently
• Outline their current practice
• Pilot test evaluate new approaches

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PAIN CQI Project
STEP I
STEP II
STEP III
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Examples of Changes

• Increase awareness about pain
• Pain as 5th vital sign buttons
• New policies protocols
• Developed protocol how to assess residents with
  pain at each MDS
• Comfort boxes
• Changed flow sheets to include pain
• Adopted pain intensity rating scales

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Remeasuring Practice

• After 12 months each team collected information
  on their practice
• used MDS to identify 20 residents with pain
• used same two page collection form

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Measures about Assessment

• of residents with pain who had a complete
  assessment of pain
• location
• intensity
• what made it worse
• what made it better
• response to treatments
• residents with a pain intensity scale used to
  monitor pain

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Treatment Measures

• residents with non-pharmacologic approach to
  treat pain
• residents with pain medication prescribed
• PRN basis vs regular schedule
• WHO step 1 vs step 2 or 3
• Step 1 NSAID or acetominophen
• Step 2 weak opiod (e.g. codeine)
• Step 3 strong opiod (e.g. oxycontin)

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WE thank..

• Participating NHs
• List all their names.

• RIQIP
• Gail Patry
• Diane DAmbra
• Pam McCue
• Melissa Miranda
• Brown University
• Terry Rochon
• Debra DeSilva
• Jeff Edmonds