1130 Kaiser et all.ppt - ASPMNcompared to VSN/SN pairs for all items except for association for patient sounds on the Behavioral Subscale MOPAT Item SN Pairs (n=90) SN and VSN Pairs

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Challenges and Approaches to Pain

Assessment Research in

Karen Snow Kaiser, PhD, RNDeborah McGuire, PhD, RN, FAAN Karen Soeken, PhD JoAnne Reifsnyder, PhD, ACHPN Timothy Keay, MD, MA-TH

Non-communicative Palliative Care Patients in Acute Care

Pain Assessment in Non-communicative Palliative Care Patients

(1 R01 NR 009684-01A1)

Principal Investigator:

Deborah B. McGuire, PhD, RN, FAAN

Research supported by a grant from the

National Institute of Nursing Research

Acknowledgement

Objectives

Identify challenges with clinical implications that are associated with pain measurement tool research in adult non-communicative, non-demented palliative care patients.

Discuss potential approaches to address the above challenges.

Discuss the relevance of the challenges and approaches to non-pain symptom assessment in patients who can’t self report.

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Background

Pain management is a right for all patients

Assessing pain in non-communicative patients poses formidable challenges to clinicians and researchers

Limited information exists about pain assessment in these pts.Limited number of tools for the adult non-demented patient

Limited generalizability

Psychometric testing often also used patients who self report

What are the population specific issues

How can these issues be addressed?

Background

Pain management is a right for all patients

Assessing pain in non-communicative patients poses formidable challenges to clinicians and researchers

Limited information exists about pain assessment in these pts.Limited number of tools for the adult non-demented patient

Limited generalizability

Psychometric testing often also used patients who self report

What are the population specific issues

How can these issues be addressed?

Study Aims

Aims of the study:

test the reliability and validity of the Multidimensional Objective Pain Assessment Tool (MOPAT) for assessing acute pain in non-communicative palliative care patients in an inpatient tertiary acute care hospital and in the inpatient units of a community-based hospice

appraise the clinical utility of the MOPAT when used by nurses to assess acute pain in non-communicative patients in these settings

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Study Aims

Aims of the study:

test the reliability and validity of the Multidimensional Objective Pain Assessment Tool (MOPAT) for assessing acute pain in non-communicative palliative care patients in an inpatient tertiary acute care hospital and in the inpatient units of a community-based hospice

appraise the clinical utility of the MOPAT when used by nurses to assess acute pain in non-communicative patients in these settings

Setting

Hospice of Lancaster County (Hospice and Community Care)

Screened patients in 2 inpatient units to find eligible patients

Setting

Screened patients in 22 inpatient units to find eligible patients

University of Maryland Medical Center (UMMC)

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Study Design

Instrument development Variability desired

Cross-sectional approach at UMMC Pairs of nurse raters assessed patients before and after a pain-

relieving intervention

• Study Nurse (SN) pairs

• Volunteer Staff Nurse (VSN) and SN pair

Importance of Setting, Sample and Inclusion/Exclusion Criteria

Major goal – Generalizability (applicability) of the findings in the clinical settingVariety of:

• Patient types/conditions (injuries and illnesses)

• Painful events

• Settings

Challenges

During the course of developing and conducting this pain instrument testing study, the research team identified several challengesPatient eligibility

Rater subjectivity

Informed consent

Enrollment

Clinical Implications

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Presentation Scope

Challenges were similar in both sites

Solutions were developed by:Research team

+ Multidisciplinary Advisory BoardSome solutions, though similar, were tailored to the

settingThis presentation focuses on solutions identified

in the acute care setting

Challenges in the Grant Development Phase

Associated with eligibility criteria

Type of painAcute pain, not chronic pain, is believed to be associated

with physiologic changes

MOPAT Physiologic Subscale

Challenges in the Development Phase

Classification of painBreakthrough

Movement related

Episodic

Procedural

Uncontrolled

Goal – develop broad yet unique categories that were clinically applicable and included most/all acute pain

Concepts overlap+/- foundations in chronic pain

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Patient Eligibility Challenge

Category Operational Definition

Episodic pain Pain that occurs briefly during functional activities such as bathing, turning, getting in or out of bed, or during physical or occupational therapy.

Procedural pain

Pain that occurs as a result of a procedure such as peripheral blood draws, suctioning, dressing change, debridement, or nasogastric tube placement.

Uncontrolled pain (escalating persistent)

Pain characterized by increasing intensity that appears to be due to underlying disease, new trauma, other medical conditions, or inadequate analgesia.

Foley, K. 2005. Acute and Chronic Cancer Pain Syndromes Chapter 8.2.2. p. 298-316 In Doyle, D. Hanks, G., Cherney, N.I., Calman, K. (Eds.) Oxford Textbook of Palliative Medicine 3rd ed. Oxford University Press. New York, NY.

Mercadante, S., Radbruch, L., Caraceni, A., Cherny, N., Kaasa, S., Nauck, F., Ripamonti, C., De Conno, F., and The Steering Committee of the European Association for Palliative Care (EAPC) Research Network 2002. Episodic (Breakthrough) Pain: Consensus Conference of an Expert Working Group of the European Association for Palliative Care. Cancer. 94:832-839

Predominant Type of Pain

Episodic pain 90 (55%)

Procedural pain 69 (42%)

Uncontrolled pain 4 (3%)

N = 163

Primary Cause of Pain

Suctioning 44 (27%)Turning 39 (24%)Out of bed to chair 23 (14%)Range of motion/ Physical therapy 9 (6%)Dressing change 6 (4%)

Blood Draw 4 (3%)Intravenous insertion 4 (3%)Bathing 3 (2%)Inadequate analgesic 3 (2%)Nasogastric insertion 3 (2%)Other 25 (15%)

N = 163

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Patient Eligibility Criteria

18 years of age or older

Meet WHO definition for receiving PCLife-threatening illness or injury or

Pain and other problems of a physical, psychosocial, or spiritual nature; or an illness that could, over time, result in death

Did not have to be receiving palliative care

Have a diagnosis or condition known to cause acute pain

Unable to communicate their pain by self report due to any non-communicative state

Original Patient Exclusion Criteria

< 18 years of age

Documented history of dementia

Receiving paralytic agents

Richmond Agitation Sedation Scale (RASS) score

= -5

Challenges in the Run-In Phase

Related to Patient Eligibility

Goal – ensure screening measures and the MOPAT could be used in eligible patients

Led to additional Exclusion CriteriaCertain neurologic conditions

• Patients with ICP monitors (opioids are used for other purposes)

Co-morbid conditions that influence the applicability of screening and assessment tools

• Quadriplegia (MOPAT and RASS)

• Severe hearing and vision impairment (RASS)

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Partial MOPAT Behavioral Subscale

Behavioral Pain

Indicators

0 (None or

Normal)

1 (Mild) 2 (Moderate) 3 (Severe)

Restless Quiet Slightly restless (fidgety)

Moderately restless (tossing/turning)

Very restless (agitated, constant movement)

Tense Muscles

(Muscle Tension)

Relaxed Slight tenseness (Guarding)

Moderate tenseness (sensitivity or mild resistance to movement)

Extreme tenseness (stiffness or total body rigidity)

Richmond Agitation and Sedation Scale

Score Term Description

+4 Combative Overtly combative, violent, immediate danger to staff

+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive

+2 Agitated Frequent non-purposeful movement, fights ventilator

+1 Restless Anxious but movements not aggressive vigorous

0 Alert and calm

-1 Drowsy Not fully alert, but sustained awakening (eye-opening/eye contact) to voice (>10 sec)

-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)

-3 Moderate sedation Movement or eye opening to voice (but no eye contact)

-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation

-5 Unarousable No response to voice or physical stimulation

When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum

http://www.mc.vanderbilt.edu/icudelirium/docs/RASS.pdf

Effect on Accrual

163 non-communicative adult palliative care patientsMale 107 (66%), Female 56 (34%)

Age Mean = 52.6, SD = 18.72

Racial Category # (%)Asian 5 (3%)Black/Afro-American 48 (29%)White 108 (66%)

Unknown/ Not Reported 2 (1%)

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Effect on Accrual

Grouped by ICD-9 Code

Injury and Poisoning (800-999) 89 (55%)

Infectious and Parasitic Diseases (001-139) 19 (10%)

Diseases of the Circulatory System (390-459) 11 (7%)

Diseases of the Digestive System ( 520-579) 10 (6%)

Neoplasms (140-239) 10 (6%)

Diseases of the Respiratory System (460-519) 9 (6%)

Other 14 (9%)

N = 163

Major Medical Diagnosis or Injury

Effect on Accrual

Traumatic brain injury 62 (38%)Sedation in the setting of mechanical

ventilation/ chemical sedation44 (27%)

Expressive/receptive aphasia 19 (12%)Shock (cardiac, hypovolemic, septic) 11 (7%)Stroke 8 (5%)Hypoxia/anoxia 6 (4%)Delirium 4 (2%)Other 9 (6%)

N = 163

Primary Reason for Non-communication

Implementation Issue

Eligibility ChallengeRapidly fluctuating medical conditions, sedation levels, and

communication ability meant patient’s eligibility status changed quickly

Goal – Determine all patient’s eligibility status immediately prior to MOPAT use

Solution - screen for patient’s ability to self report immediately prior to using measure using the question,

• Add “Are you in pain?” to the RASS

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Rater Subjectivity Challenge

Subjective assessment required by the MOPAT Item descriptions could have different meanings to different

people

Potential for discrepancies in nurse: ratings of subjective pain behaviors

• Restlessness

• Tense muscles

• Frowning

• Patient sound

Determining a change in the patient’s usual physiologic scores

Behavioral Dimension

MOPAT Behavioral Subscale Item

Restless

Quiet = 0

Slightly restless; fidgety = 1

Moderately restless; tossing = 2

Very restless; agitated = 3

Raters must be able to discriminate accurately between various levels

The degree to which observers’ (or judges’) ratings on a measure agree

Interrater Reliability

r = <1

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Rater Subjectivity Challenges

26 VSNs (required informed consent) performed 72 before and after ratings paired with a SN Mimics the “real world”

Have varied backgrounds

Used MOPAT intermittently during the study

VSN Demographics

Total (n = 47)

Age (Mean, SD) 36.3 (SD 10.7)

Highest Level of Education (n, %)

Diploma 2 (4%)

Associate degree 10 (21%)

Bachelors degree 30 (64%)

Masters degree 5 (11%)

Years as a Nurse (Mean, SD) 9.2 (SD 9.3)

Years in Current Position (Mean, SD) 4.2 (SD 5.2)

How often encounter patients unable to communicate (n, %)

Rarely 4 (9%)

Occasionally 7 (15%)

Frequently 24 (51%)

Constantly 12 (25%)

Goal – reduce variation between raters

Potential solutionsDevelop more informative descriptions

• Changes the existing tool and could decrease inter-rater reliability

Standardize training

Retraining (review) throughout the study

Rater Subjectivity Challenge

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Developed a training video of 3 before and after pain intervention scenarios

Developed consensus ratings for each scenario using expertsPalliative care and pain nurses, ICU and non-ICU

background, some with a geriatric background

RetrainingPerformed once throughout the course of the study

Rater Subjectivity Solution

Standardized Training

Study overview

Reviewed MOPAT scoring tool

Showed before and after pain intervention video clipsShowed each before and after video clip scenario

individually

Rater scored each video clip and discussed differences between their and the consensus ratings

Rater Subjectivity

Inter-rater reliability was higher between SN pairs compared to VSN/SN pairs for all items except for association for patient sounds on the Behavioral Subscale

MOPAT ItemSN Pairs (n=90) SN and VSN Pairs (n=72)

Association1 Kappa Association1 KappaRestless .89 .56 .83 .40

Tense Muscles .90 .63 .82 .45Frowning/Grimacing .91 .49 .79 .35

Patient Sounds .90 .65 .91 .54Mean: Behavioral Dimension .90 .58 .84 .44

1 Gamma for ordinal level data on Behavioral Dimension. All values are significant at p<.001.NOTE: Strength of agreement for kappa: 0 = poor, .01 -.20 = slight, .41-.60 = moderate,.61-.80 = substantial and .81-1 almost perfect.

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Rater Subjectivity

Inter-rater reliability was higher between SN pairs compared to VSN/SN pairs for all items except for heart rate on the Physiological Subscale

MOPAT ItemSN Pairs (n=90) SN and VSN Pairs (n=72)

Association1 Kappa Association1 KappaBlood Pressure .53 .53 .54 .54

Heart Rate .44 .44 .61 .61Respirations .71 .71 .49 .49Diaphoresis .44 .44 .39 .39

Mean: Physiological Dimension .53 .53 .51 .51

1 Gamma for ordinal level data on Physiological Dimension. All values are significant at p<.001.NOTE: Strength of agreement for kappa: 0 = poor, .01 -.20 = slight, .41-.60 = moderate,.61-.80 = substantial and .81-1 almost perfect

Next Grant

To improve reliabilityScore subscales separately

Use a standardized patient• Demonstrate each level of each behavior

Relevance to Other Symptoms

Patient eligibility criteria

Rater subjectivity

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Challenges & Solutions - Review

Patient eligibility:Operational definitions should maximize generalizabilityExclusion criteria should be relatively unrestrictiveAssess patients prior to use of a non-verbal tool

Rater subjectivity:Robust Training

Retraining

These challenges and approaches may be applicable to non-pain symptom assessment in patients who can’t self report.

Questions?