Pain Assessment & Management Data of Learning & SharingJune 27, 2017

Session Summary

Current Nursing Home Data:

Long-Stay residents reporting pain at least daily or horrible/excruciating pain at any frequency on target assessment.

2013Q1

2013Q2

2013Q3

2013Q4

2014Q1

2014Q2

2014Q3

2014Q4

2015Q1

2015Q2

2015Q3

2015Q4

2016Q1

2016Q2

2016Q3

2016Q40

2

4

6

8

10

12

14

Pain (LS) - 4 Quarter Rolling Average

State LeadingAge Minnesota National

Short-Stay residents reporting pain at least daily or horrible/excruciating pain at any frequency on target assessment.

2013Q1

2013Q2

2013Q3

2013Q4

2014Q1

2014Q2

2014Q3

2014Q4

2015Q1

2015Q2

2015Q3

2015Q4

2016Q1

2016Q2

2016Q3

2016Q40

5

10

15

20

25

30

Pain - (SS) - 4 Quarter Rolling Average

State LeadingAge Minnesota National

Pain Assessment Discussion:

Key Challenges Successful or Potential SolutionsResident/patient understanding/perception of pain and pain scale

Residents/patients: Lack of understanding of pain levels and

pain scale; do residents/patients understand what the numbers of the pain scale represent?

Understanding what is an acceptable level of pain

Residents feel they must rate their pain high to get pain medication

Pain perception by residents/patients, e.g., indicating a “10” for pain with a smile; very active with no signs of pain but always rate pain 6-7 out of 10

Fear of having pain Pain tolerance is different for all residents Resident/patient education

Staff: Consistency in completing the assessment;

knowing how to ask the questions and what questions to ask; interviewer can lead the resident/patient

Having the time to do the assessment accurately

Lack of knowledge/experience with pain assessment

Lack of appreciation for the importance of pain assessment

Not taking time to understand the underlying causes of pain; taking time to understand the patient/resident history, diagnoses

Taking time to know the resident/patient Taking time to know what the

resident/patient wants as far as comfort level

Timing of assessment is important.

Residents/patients: Educate residents/patients on levels of

pain; educating patients on admission and during shifts has reduced their rate of reported pain

One facility has had a good response to a pain scale which includes numeric ratings, faces, and a description of pain at each pain level

Assuring residents/patients/families that having a lower pain score will still get attention (and follow through)

Educate and remind residents/patients that there are options for pain relief other than medications

Advocate/re-educate residents/patients who rate their pain low but they look very uncomfortable and distressed.

Staff: Have a process in place to integrate pain

history, causes of pain, resident history into pain assessment.

Have a process in place to gather and communicate resident/patient expectations/wishes related to comfort level

Have a process in place to provide consistency in timing of assessments. First thing in morning and after therapy not effective; be aware of possible sundowning effect for some residents/patients in late afternoon/evening.

Pain scales laminated and placed in resident/patient rooms and on med carts

Initial and on-going education for staff on how to effectively conduct an assessment and the importance of a good pain assessment.

Have clear processes in place and accessible to staff for conducting assessments.

Have processes in place to reinforce

Assessment Tool Design: MDS assessment tool is not telling of how

the overall pain. Question working tends to capture momentary and brief pain rather than average/overall pain making appropriate pain management more challenging.

What is the worst pain you have had in the last 5 days? If the resident says “10”, it is recorded and this is not reflective of their average pain.

education and conduct observations of the application of practices to check for drift in behavior and provide real-time staff coaching

Recognize staff effectively implementing key practices

Assessment Tool Design: Add note in MDS about the discrepancy

of average pain vs. brief momentary pain Ideally - reword the MDS to say, “What

would you say your pain has been on average……”

Dementia Difficult to assess pain in

patients/residents with cognitive impairments

May not be able to express in words that they have pain, where it is located, and the intensity

Have process in place to gather resident/patient diagnosis, history, family perceptions; identify life losses, comfort habits, etc.

Have a process in place to gather information and perceptions from CNAs

Participants have found the Pain Assessment in Advanced Dementia (PAINAD) Scale to be an effective pain assessment tool for this population (have not found numeric or face pain scale to be effective for this population)

Early morning assessments are not effective

Removal of med carts so that residents will not attribute it to time to get pain meds

Find out from family what makes residents more calm

Utilize observed behaviors, such as moaning while sleeping, to aid in pain assessment

Implement an effective sleep program

Pain Management Discussion:

Key Challenges Successful or Potential SolutionsPain Medications

Residents/patients are not always aware of all pain medication and non-pharma options available

Residents/patients/families aren’t aware of medications being taken and reasons

Delays in getting medications and refills Timing of medications Stigmatism of pain meds Finding a balance between sedation and

pain control PRN scheduling Residents/patients won’t ask for PRNs PRN order parameters are too many;

confusing Getting MD/NP on board with writing

orders Pain contracts (primary md does not

want to adjust dosage because resident had a pain contract)

Staff following up on meds Time delay between med request and

delivery Inconsistency in therapy schedules make

it difficult to time pain meds prior to therapy session

Start with low doses to avoid over-sedation and side effects

Know what dose they were getting in the hospital

Explain all options for pain management including non-pharmacological

Simplify med parameters and translate medication regiment for patients/residents/families

Identify pain levels and interventions pre-admission through nurse to nurse communication; find out medications and last-dose given

Have a cheat sheet for nurse to nurse report to convey what patient is taking, how much, pain level rating, last time they took the med, hard script

Make pain management a priority Use patient discharge resources from

hospital for post-acute patients, such as ortho discharge instructions and education

Have therapy establish set appointment times to better coordinate pain medication timing

Provider to provider communication for continuity of care

Work with hospitals to fax discharge orders to facility and pharmacy

Work with hospitals to medicate patient prior to discharge and send medications with patient

Social workers fax orders to pharmacy when doing discharges

Delivery of pain meds from a local pharmacy to get them in a timely manner

Have an e-kit on site Try to change vocabulary to say “do you

have discomfort”, instead of “pain” Education on other options for

medications. Try milder pain meds such as Tylenol and or Tramadol.

Have a process in place for good

communication between providers for patients/residents on pain contracts

Have a process in place for staff to consistently follow up on meds

Pharmacy presentation with a pharmacist for new hires and ongoing education for regular staff

Make sure that orders for pain meds are available

Use the whiteboard in the rooms to record PRN medication administration

Non-Pharmacological Strategies Lack of knowledge of alternative

interventions Lack of systems/processes for providing

alternative interventions Resistance by providers and staff to non-

pharmacological interventions Culture of clinical/pharmacological

interventions

On-going education and reinforcement of the use of non-pharma interventions

Chart audits and observational audits of implementation of practices with real-time coaching as needed

Make non-pharma part of the culture of your organization starting with your medical director, NPs, MDs, Managers; make it fun!

Interview resident/resident-representative regarding what non-pharma interventions have worked or not worked in the past

Know the resident history (what they did for a living; what they enjoyed doing)

Update care plan and communicate with team frequently

Pain interdisciplinary team meetings weekly/monthly

Explain to residents/patient/family all options for pain management including non-pharmacological

Identify source of pain (e.g., physical, environmental, psychological) and explore options for addressing the source

Warm blankets/weighted blankets Acupuncture Aromatherapy Music Comfort foods Effective sleep program One size does not fit all – for example,

aromatherapy doesn’t work for everyone

Dementia

Difficult to manage pain in patients/residents with cognitive impairments

May not be able to express in words that they have pain, where it is located, and the intensity

Good history is the key! Reduce sensory overload, e.g., white

noise in hallways to reduce noise levels Special comfort items (stuffed animals,

baby doll, blankets, clothes) Pet therapy Familiar caregivers Range of motion Learning circles – provides distractions

from thinking about pain Be cognizant of timing of meds Providing a restaurant style dining

experience had a significant impact on pain rates for one facility

Water therapy Music therapy Massage or light touch therapy Essential oils Blanket warmer (weighted blankets have

not been found to be effective for this population)

Cold packs Special lighting Effective sleep program Treating underlining non-pain issues like

depression and anxiety Hospice team can help Getting the right medication routine Engage staff in ideas Engage providers Pressure ulcer prevention; early detection What works for one person may not work

for another; just keep trying!

Accessing the LeadingAge Minnesota Pain Management Toolkit:

1) You will need to Log In to the LeadingAge Minnesota website2) Click on “Provider Resources” and “Performance Improvement Tools”

3) You will then see the list of toolkits; Click on “Pain Management”