Evidence-Based Pain Management in the Ambulatory Setting Michele Farrington, BSN, RN, CPHON Trudy Laffoon, MA, RN-BC Carmen Kealey, MA, RN Cindy Dawson, MSN, RN, CORLN ASPMN ® 25 th National Conference September 18, 2015 0830 – 0930 1 Evidence-Based Pain Management in the Ambulatory Setting ASPMN ® 25 th National Conference Michele Farrington, BSN, RN, CPHON Trudy Laffoon, MA, RN-BC Carmen Kealey, MA, RN Cindy Dawson, MSN, RN, CORLN Conflict of Interest Disclosure The speakers do not have any conflicts of interest or disclosures to report. Objectives Outline steps in the evidence-based practice process using the Iowa Model of Evidence-Based Practice to Promote Quality Care and Implementation Guide. Describe an EBP project regarding translation of evidence-based interventions related to needlestick pain into practice in ambulatory settings.
22
Embed
Evidence-Based Pain Management in the Ambulatory Setting … Conference Documents...Evidence-Based Pain Management in the Ambulatory Setting Michele Farrington, BSN, RN, CPHON Trudy
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
11
Problem Focused Triggers1. Risk Management Data2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data5. Identification of Clinical Problem
Knowledge Focused Triggers1. New Research or Other Literature2. National Agencies or Organizational
Standards & Guidelines3. Philosophies of Care4. Questions from Institutional
Standards Committee
Is this Topica PriorityFor the
Organization?
Form a Team
Yes
= a decision point
Titler et al., 2001
Iowa Model
Purpose
■ The purpose of this evidence-based practiceproject was to ensure a consistent, standardizedapproach when offering interventions formanagement of needlestick pain across adult andpediatric ambulatory clinics at a large academicmedical center.
Critique & Synthesize Research for Use in Practice
Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based
Practice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Guideline
Base Practice on OtherTypes of Evidence1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
12
Synthesis of Evidence
■ Pain management recognized as right of allpatients since 2001 by The Joint Commission
■ Pain – prevalent global health concern; one ofmost common reasons people seek health care
■ Pain assessment and treatment – complex■ Multifactorial influences to assessment and
treatment provided by health care team■ Ineffectively treated pain negatively impacts
overall healthcare costs
Bernhofer, 2011; De Ruddere et al., 2011; Fishman et al., 2013; Gaskin & Richard, 2011; Hirsh et al., 2010; Layman Young et al., 2006; Schreiber et al., 2014; The Joint Commission, 2014
Abuelkheir et al., 2014; Baxter et al., 2009; Canbulat et al., 2015; Chambers et al., 2009; Hogan et al., 2014; Inal & Kelleci, 2012; Whelan et al., 2014; Windle et al., 2006
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
15
Patient Education
Interventions Poster
Interventions TableInterventions for Needlestick Pain
Choose option/combination of options best meets patient need considering: Time, Age, Allergies, Contraindications, & Patient/Family Preference
Use if:
<30 minutes prior to
needlestick
Use if:
30-60 minutes prior to
needlestick
Use if:
>60 minutes prior to
needlestick
Order Per Protocol
(Yes/No/Not Applicable)
Policy Number/Title Additional Information
Sucrose > 32 weeks gestation (effectiveness 3 months – 1 year of age)
Not Applicable – Order Not Needed
N-CWS-PEDS-02.175 “24% Sucrose Solution, Use of”
Obtained from Stores(PS# 992213)
Breastfeeding Dependent on age/NPO status; ability of infant to coordinate suck/swallow
2-3 minutes prior toprocedure, during
procedure, and after procedure
Comfort Positioning, Distraction, or Mindfulness-Based Stress Reduction
Developmentally appropriate interventions Buzzy
Without cold wings: >46 weeks gestational age – 2 years of age and sickle cell disease With cold wings: >2 years of age and desired
Not Applicable –Order Not Needed
N-CWS-PEDS-02.013 “Buzzy® Usage”
Obtained from Stores (PS# 59950 – Buzzy;
PS# 59951 – Ice Pack Wings)
Bacteriostatic Normal Saline >30 days of age; able to tolerate 30 gauge needle; no allergy to benzyl alcohol
No No Yes N-08.092 “Protocol for the Use of Bacteriostatic 0.9% Sodium Chloride with
Benzyl Alcohol Prior to Venipuncture for IV Cannulation or Lab Draw”
RN OnlyObtained from Stores
(PS# 992171 – Bacteriostatic Normal Saline; PS# 038531 –
30 gauge needle)
Pain Ease >3 years of age; able to understand cold spray is used to help with pain versus induce pain; not for use with blood cultures
No No Yes N-08.094 “Protocol for the Use of a Topical Anesthetic Skin Refrigerant/Vapocoolant for
Needle Procedures”
Obtained from Stores (PS# 992130)
LMX4 >37 weeks gestational age; no allergy to lidocaine/amides; caution in liver failure
No Yes N-08.090 “Protocol for Topical Numbing Agents: EMLA, L.M.X.4™ Cream”
MA Competency Checklist before able
to administer; Obtained from
Pharmacy EMLA
>37 weeks gestational age; no allergy to lidocaine/prilocaine/ amides; methemoglobinemia concern for infants <12 months of age; some blanching/ vasoconstriction; caution in liver failure
No No Yes N-08.090 “Protocol for Topical Numbing Agents: EMLA, L.M.X.4™ Cream”
Staff Knowledge 57.5% correct (pre) improved to 69.1% correct
(post)
Evaluation – Staff Questionnaire (cont.)
StronglyDisagree
StronglyAgree
Evaluation – Process
Customized question added to Ambulatory PressGaney® survey, starting March 2015
Patient feedback received from a staff member... “I used the Buzzy yesterday on a women in her late 60s … had
been stuck several times a couple of weeks ago, but was still a little bruised and tender … used continuous mode while drawing … blood and she loved it! She reported she did not feel a thingand thought it was the neatest thing ever!”
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
18
A special thanks to the Super-Users who helped with the hands-on pain competency training: Sharon Baumler, Tracy Bloebaum,Carol Callaghan, Lieshia Davis, Marybeth Doerrfeld, Amy Ellsworth, Glenda Eubanks, Karlene Fuller, Marla Grosvenor, Jennifer Johnson, Nancy Mata, Sarah Smith, Deborah Steinbaker, Maggie Stoner, Jane Utech, Marie Voegele, and Marilyn Wurth!
Thank you to Kristin Eveland and Terri Werling for all of their assistance!
Abuelkheir, M., Alsourani, D., Al-Eyadhy, A., Temsah, M-H., Meo, S.A., & Alzamil, F. (2014). EMLA® cream: A pain-relieving strategy for childhood vaccination. Journal of International Medical Research, 42(2), 329-336.
Baxter, A.L., Leong, T., & Mathew, B. (2009). External thermomechanical stimulation versus vapocoolant for adult venipuncture pain: Pilot data on a novel device. Clinical Journal of Pain, 25(8), 705-710.
Bernhofer, E. (2011). Ethics and pain management in hospitalized patients. OJIN: The Online Journal of Issues in Nursing, 17(1),http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/ OJIN/Columns/Ethics/Ethics-and-Pain-Management-.html.
Bick, D., & Graham, I. (2010). Evaluating the impact of implementing evidence-based practice. United Kingdom: Wiley Blackwell Publishing and Sigma Theta Tau International.
Canbulat, N., Ayhan, F., & Inal, S. (2015). Effectiveness of external cold and vibration for procedural pain relief during peripheral intravenous cannulation in pediatric patients. PainManagement Nursing, 16(1), 33-39.
Chambers, C.T., Taddio, A., Uman, L.S., McMurtry, C.M., & HELPinKIDS Team. (2009). Psychological interventions for reducing pain and distress during routine childhood immunizations: A systematic review. Clinical Therapeutics, 31(Suppl 2), S77-S103.
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
19
References (cont.)
Crucial Skills. (2014). All washed up with Hyrum Grenny. Available at: http://www.crucialskills.com/2009/09/all-washed-up/.
Cullen, L., & Adams, S. (2012). Planning for implementation of evidence-based practice. Journal of Nursing Administration, 42(4), 222-230.
Cullen, L., Hanrahan, K., Tucker, S., Rempel, G., & Jordan, K. (2012). Evidence-based practice building blocks: Comprehensive strategies, tools and tips. Iowa City, IA: Nursing Research and Evidence-Based Practice, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics.
Czarnecki, M.L., Turner, H.N., Collins, P.M., Doellman, D., Wrona, S., & Reynolds, J. (2011). Procedural pain management: A position statement with clinical practice recommendations. Pain Management Nursing, 12(2), 95-111.
De Ruddere, L., Goubert, L., Prkachin, K.M., Louis Stevens, M.A., Van Ryckeghem, D.M.L., & Crombez, G. (2011). When you dislike patients, pain is taken less seriously. Pain, 152, 2342-2347.
Fishman, S.M., Young, H.M., Arwood, E.L., Chou, R., Herr, K., Murinson, B.B., … Strassels, S.A. (2013). Core competencies for pain management: Results of an interprofessional consensus summit. Pain Medicine, 14(7), 971-981.
References (cont.)
Gaskin, D.J., & Richard, P. (2011). The economic costs of pain in the United States. In: Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press.
Hirsh, A.T., Jensen, M.P., & Robinson, M.E. (2010). Evaluation of nurses’ self-insight intotheir pain assessment and treatment decisions. The Journal of Pain, 11(5), 454-461.
Hogan, M.E., Smart, S., Shah, V., & Taddio, A. (2014). A systematic review of vapocoolants for reducing pain from venipuncture and venous cannulation in children and adults. Journal of Emergency Medicine, 47(6), 736-749.
Inal, S., & Kelleci, M. (2012). Distracting children during blood draw: Looking through distraction cares is effective in pain relief of children during blood draw. International Journal of Nursing Practice, 18(2), 210-219.
Layman Young, J., Horton, F.M., & Davidhizar, R. (2006). Nursing attitudes and beliefs in pain assessment and management. Journal of Advanced Nursing, 53(4), 412-421.
Logan, J., & Graham, I.D. (1998). Toward a comprehensive interdisciplinary model of healthcare research use. Science Communication, 20(2), 227-246.
References (cont.)
McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Students’ Store.
Parry, G. J., Carson-Stevens, A., Luff, D. F., McPherson, M. E., & Goldmann, D. A. (2013). Recommendations for evaluation of health care improvement initiatives. Academic Pediatrics, 13(Suppl 6), S23-S30.
Rogers, E. (2003). Diffusion of innovations (5th ed.). New York, NY: The Free Press.
Schreiber, J.A., Cantrell, D., Moe, K.A., Hench, J., McKinney, E., Preston Lewis, C., … Brockopp, D. (2014). Improving knowledge, assessment, and attitudes related to pain management: Evaluation of an intervention. Pain Management Nursing, 15(2), 474-481.
Shah, V., Taddio, A., Rieder, M.J., & HELPinKIDS Team. (2009). Effectiveness and tolerability of pharmacologic and combined interventions for reducing injection pain during routine childhood immunizations: Systematic review and meta-analyses. Clinical Therapeutics, 31(Suppl 2), S104-S151.
The Joint Commission. (2014). Facts about pain management. http://www.jointcommission.org/topics/ pain_management.aspx. Accessed February 3, 2014.
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
20
References (cont.)
Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., … Goode, C.J. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497-509.
Veniegas, R.C., Kao, U.H., Rosales, R., & Arellanes, M. (2009). HIV prevention technology transfer: Challenges and strategies in the real world. American Journal of Public Health,99(Suppl 1), S124-S130.
Whelan, H.M., Kunselman, A.R., Thomas, N.J., Moore, J., & Tamburro, R.F. (2014). The impact of a locally applied vibrating device on outpatient venipuncture in children. Clinical Pediatrics, 53(12), 1189-1195.
Windle, P.E., Kwan, M.L., Warwick, H., Sibayan, A., Espiritu, C., & Vergara, J. (2006). Comparison of bacteriostatic normal saline and lidocaine used as intradermal anesthesia for the placement of intravenous lines. Journal of PeriAnesthesia Nursing, 21(4), 251-258.
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
NoYes
Yes
Is ChangeAppropriate for
Adoption inPractice?
YesInstitute the Change in Practice
No
Continue to Evaluate Qualityof Care and New Knowledge
No
Disseminate Results
Problem Focused Triggers
1. Risk Management Data2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data5. Identification of Clinical Problem
Knowledge Focused Triggers
2. National Agencies or OrganizationalStandards & Guidelines
3. Philosophies of Care4. Questions from Institutional Standards Committee
1. New Research or Other Literature
ConsiderOther
Triggers
Is this Topica Priority For the
Organization?
Form a Team
Is Therea SufficientResearch
Base?
Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based
Practice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Guideline
Base Practice on Other Types of Evidence:1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory
Conduct Research
Monitor and Analyze Structure, Process, and Outcome Data• Environment• Staff• Cost• Patient and Family
The Iowa Model of Evidence-Based Practice to Promote Quality Care
= a decision point Titler, M.G., C., Steelman, V.J., Rakel., B. A., Budreau, G., Everett, L.Q., Buckwalter, K.C., Tripp-Reimer, T., & Goode C. (2001). The Iowa Model Of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497-509.
REQUESTS TO: Department of Nursing
University of Iowa Hospitals and Clinics Iowa City, IA 52242-1009
Implementation Strategies for Evidence-Based Practice Co
nnec
ting
with
Clin
ician
s, Or
gani
zatio
nal L
eade
rs
and
Key S
take
hold
ers
Highlight advantages* oranticipated impact*
Highlight compatibility* Continuing education
programs* Sound bites* Journal club* Slogans & logos Staff meetings Unit newsletter Unit inservices Distribute key evidence Posters and postings/fliers Mobile ‘show on the road’ Announcements & broadcasts