Improving Quality of Care Through Pain Management

• Patrick Bobst

A Qualitative Study

Quantitative research involves testing hypotheses, making predictions, studying specific variables, collecting numbers and statistics, identifying statistical relationships, and making observations under controlled conditions (Johnson & Christensen, 2008). None of the aforementioned attributes appear in chapter 17 “Improving the quality of care through pain assessment and management”. Hence. this chapter written byWells, Pasero, & McCaffery, (2008) is a detailed deductive qualitative analysis which aims to increase opportunities to develop empirically supported ideas and theories with applicable relevance in the field of pain management for healthcare practitioners. Unlike inductive analysis, applied when not enough former knowledge about a phenomenon is known, deductive content analysis is used when the structure of analysis is initiated based on previous knowledge and with the intent to test a theory(Elos & Helvi, 2008). The authors of chapter 17 provided qualitative research by studying the issue of pain control as a whole without immersion into variables. They defined the purpose of the study by subjectively understanding and interpreting interactions with words, identifying patterns and themes, and making observations of occurrences in a natural environment(Johnson & Christensen, 2008). Qualitative research is more concerned with describing social meaning and therefore provides the flexibility to follow ideas and explore processes(McGonigle & Mastrian, 2012).

Research Problem

The level of pain a patient experiences is emerging as the fifth vital sign in health assessments statuses (Ju-Ling & Wen-Chu, 2013). Pain is a common occurrence and an expectation in hospitalized patients especially during the postoperative period; yet despite the availability of analgesics along with national guidelines to manage pain a disconnect remains in in proper pain management resulting in undertreatment for about 50% of patients with moderate to severe pain(Wells et al., 2008). Inadequately managed pain can lead to an arsenal of negative adverse physical and psychological outcomes including immune system suppression resulting in infections and poor healing, sympathetic activation causing cardiac ischemia and ileus, reducing mobility resulting in deep vein thrombosis, as well as pulmonary embolus, or pneumonia(Nwachukwu, 2012). All mentioned adverse conditions carry along the potential consequence of extending a patient’s length of stay in the hospital decreasing patient satisfaction and increasing organizational costs(Nwachukwu, 2012). The Affordable Care Act of 2010 has established changes in the way hospitals are reimbursed for services. Value-based purchasing has come to the forefront in the healthcare industry with the centers for Medicare and Medicaid services (CMS) withholding full reimbursements for poor quality care or even nonpayment for patients readmitted within 30 days. Low patient satisfaction score indicators being tracked by CMS will not only affect an organization’s bottom line but also stand to lose its reputation(Wells et al., 2008). When pain is not managed properly through an organization’s pain management policy and procedure guideline the entire collaborative team responsible for managing a patient’s pain may be liable for legal action(Wells et al., 2008).

Research Translated Into Practice

The Agency for Healthcare Research and Quality (AHRQ) focuses on current issues, patient safety and quality of healthcare providing practitioners the best research for optimal patient outcomes. AHRQ is an active participant in pushing evidence forward into practice with its Translating Research Into Practice (TRIP) initiative to generate knowledge about evidence-based care and with the TRIP-II initiative the focus is on utilizing information technology to affect translational research and health policy (McGonigle & Mastrian, 2012). The TRIP database is a clinical search engine designed to identify high-quality clinical evidence for clinical practice that utilizes contextual issues such as the magnitude of the health issue, economic costs of the problem, the reliability, relevance, and validity of the data along with the quality and consistency of the evidence (Glasgow & Emmons, 2007). The authors in the pain assessment and pain management research study utilized the TRIP database probing for the terms “pain assessment” and “pain management” in the literature search, filtered only the English language and publications dated within the last 10 years, meta-analysis, practice guidelines, literature reviews, clinical trials, and random clinical trials (RCT). To use evidence in practice, the validity of research is evaluated on an evidential hierarchy that is defined and the value is assigned to the information source on a scale from 1 to 6, one being the highest evidence from a systemic review and six being the evidence from the opinion of experts(McGonigle & Mastrian, 2012). The evidence table provided by the authors in the pain assessment and pain management study exhibits excellent research validity with multiple design types rating high on the evidential hierarchy scale listing. The authors utilized evidence from a meta-analysis study (Level 1), twelve RCT studies (Level 2), seven systematic literature reviews (Level 5), three literature reviews (Level 6), and one qualitative massage study (Level 7)(Melnyk & Fineout-Overholt, 2011). The RCT is considered the most reliable source of evidence in the hierarchy and the meta-analysis is the best quality evidence because it uses a multiple individual research studies to come to a consensus (McGonigle & Mastrian, 2012).

Practice Implications

The implications of this TRIP intervention designed to increase the use of evidence-based practice (EBP) in pain assessment and management highlights scientific evidence for practitioners to augment their clinical decision-making. Recommendations for successful implementation of pain assessment and management include education, the utilization of appropriate tools in pain assessment, a multimodal analgesic approach, continuous evaluation, and an established organizational pain management guideline. Patient and family education has been a central recommendation regarding pain management prior to any surgical procedure in that comprehensive pain evaluations can uncover patient’s attitudes, beliefs, level of knowledge, and unrealistic expectations that can be addressed(Wells et al., 2008). Wells et al. (2008) found that frequent communication, shared goals, and shared knowledge in education contributed to better pain outcomes. The most critical aspect of proper pain management is assessing pain levels on a regular basis using a standard format, and in order to meet the patient’s needs pain should be reassessed after each intervention evaluating the effects and determining whether modification is needed(Wells et al., 2008). Based upon systematic reviews of pain quality improvement studies the emphasis has shifted from processes to outcomes where clinicians recognize and treat pain promptly, involve patients and families in pain management plans, adjust pain management plans as needed, and monitor processes and outcomes(Wells et al., 2008). Utilizing a multimodal approach for pain management is recommended which includes opioids, and non-opioids such as nonsteroidal anti-inflammatory drugs, and adjunct medications such as anticonvulsants can improve the safety of the therapy (Wells et al., 2008). With safety issues regarding the use of morphine, hydromorphone, and fentyal clinicians need to be educated about safe pain management to help prevent undertreatment of pain and the resulting harmful effects. A series of systematic reviews indicate poor results and outcomes using the intramuscular route (IM) administering of an opioid analgesic (Wells et al., 2008). The IM route is painful, has an unreliable absorption time and can be dangerous since patients are often alone at the time of peak affect and can become excessively sedated, vomit, and aspiratenevertheless produces the poorest outcomes (Wells et al., 2008). Unfortunately,Wells et al. (2008) describe the evidence for nondrug techniques of pain management including relaxation, music, massage, heat and cold therapies are neither supportive nor consistent, are considered weak in reducing acute pain, and may not improve outcomes. Ample evidence revealed the appropriate use of analgesics with the proper drug at the correct interval can provide good pain relief for the majority of patients, and organizations should place their emphasis on improving assessments and administration techniques (Wells et al., 2008). The psychological, emotional, and financial toll of uncontrolled pain is monumental and everyone experiencing discomfort because of pain justly expects and needs to receive appropriate pain management.

Research Implications

The research provided supports the evidence-based treatments with analgesics in the management of pain, and appears to be effective in controlling acute pain. However, the undertreatment of acute pain remains prevalent due to the clinician’ behaviors, which includes inadequate pain knowledge, assessment skills and administration of analgesics (Wells et al., 2008). Krenzischek, Wilson, Newhouse, Mamaril, & Kane (2004) also assert a lack of pain management knowledge and the reduced usage of clinical practice guidelines is a high contributor in poor pain management. Research is needed for effective strategies in changing clinician attitudes and behaviors that will result in better pain management for patients as well as non-drug therapies (Wells et al., 2008). Wells et al. (2008) asserts, “Lack of standardization of nondrug therapies is one of the drawbacks of the current literature” (p. 11).

Integration of Informatics

The authors of this study integrated informatics through data, information and knowledge to support clinicians and patients in their decision-making regarding the best practices in accomplishing favorable outcomes and to improve the quality of care through pain assessment and management. Wells et al. (2008) utilized the informatics infrastructure to seek and manage validated studies from various sources, capture proper demographic, treatment and outcome information, and the AHRQ to share project information, results, and insights. The informatics infrastructure is critical to EBP and promotes the use of clinical judgment and knowledge with procedures and protocols to what is scientifically proven rather than what is customary(McGonigle & Mastrian, 2012). The paradigm of “this is the way I’ve done it for years “is no longer acceptable and it is upon clinicians to apply the aforementioned viable knowledge, experience, understanding, and insight derived from EBP through informatics to gain and synthesize the effervescent wisdom needed for high quality patient care and optimal outcomes.

References

Elos, S., & Helvi, K. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107-115. http://dx.doi.org/10.1111/j.1365-2648.2007.04569.x

Glasgow, R., & Emmons, K. (2007). How can we increase translation of research and to practice? Types of evidence needed. Annual Review of Public Health, 28, 413-433. http://dx.doi.org/10.1146/annurev.publhealth.28.021406.144145

Johnson, B., & Christensen, L. (2008). Educational research: quantitative, qualitative, and mixed approaches. Thousand Oaks, CA: Sage Publications.

Ju-Ling, H., & Wen-Chu, W. (2013). Factors of accepting pain management decision support systems by nurse anesthetists. BMC Medical Informatics and Decision Making, 13(16), 1-13. http://dx.doi.org/10.1186/1472-6947-13-16

Krenzischek, D. A., Wilson, L., Newhouse, R., Mamaril, M., & Kane, H. L. (2004). Clinical evaluation of the ASPAN pain and comfort clinical guideline. Journal of PeriAnesthesia Nursing, 19(3), 150-159. http://dx.doi.org/10.1016/j.jopan.2004.03.003

McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones and Bartlett.

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott, Williams and Wilkins.

Nwachukwu, C. N. (2012). Decreasing pain and length of stay in the post anesthesia care unit (PACU) by implementing the ASPAN pain and comfort guidelines (Doctoral dissertation, The Catholic University of America). Retrieved from http://aladinrc.wrlc.org/bitstream/handle/1961/10269/Nwachukwu_cua_0043A_10311display.pdf?sequence=1

Wells, N., Pasero, C., & McCaffery, M. (2008). Improving the quality of care through pain assessment and management. Rockville, MD: Agency for Healthcare Research and Quality.