Beyond Morphine: Creating an Institutional Environment of Comfort - - PowerPoint PPT Presentation

Beyond Morphine: Creating an Institutional Environment of Comfort for Children Experiencing Pain

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Text the designated surveyor ID to 22333:

Main Campus lisadavenpor389 West Campus tamaradubose684 The Woodlands dionnewalker380

Once you’ve joined, you’re ready to participate in the survey! J

CARE PROCESS TEAMS

Care Process Teams

Standardize the management and care of patient conditions Measurable outcomes Collection and use of meaningful data Strategic alignment towards managing populations across the continuum of care

Pain Care Process Team

Opioid Stewardship Workgroup Assessment Workgroup Treatment Workgroup Patient and Family Engagement and Education Workgroup

Number of Unique Patients

6,000 4,000 2,000

Opioids are Given to Patients System-Wide

Data for Academic Year 2018 (July 1, 2017 – June 30, 2018), All Campuses

Number of Unique Patients

12,000 9,000 6,000 3,000

Opioids are Given to Patients System-Wide

Data for Academic Year 2018 (July 1, 2017 – June 30, 2018), All Campuses

Jennifer Placencia, PharmD, BCPPS Rohit Shenoi, MD

Opioid Stewardship in a Pediatric World

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https://www.hhs.gov/opioids/sites/default/files/2019-01/opioids-infographic_1.pdf

The Opioid Crisis

https://www.npr.org/2019/01/14/684695273/report-americans-are-now-more-likely-to-die-of-an-opioid-overdose-than-on-the-ro

Opioid Stewardship Sticky-Notes

Risk assessments to identify potential opioid abuse/diversion § Risk assessments for all preoperative patients § Identify at-risk patients and/or families for potential

• pioid abuse/diversion

§ Risk assessment tool for families as well as patients § Risk assessment for high risk patients § Risk assessment § Risk assessment tool for patients at risk for opioid risk § Initiate risk assessment tool for patient/family

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Utilize the Prescription Monitoring Plan (PMP) § Utilize PMP for every patient an opioid is prescribed for outpatient § Ensure use of PMP Drug Monitoring Program § Every patient needs a PMP assessment for opioid RX § Hard stops for opioid prescriptions to check PMP § Hard stop in Epic ordering PMP before prescribing

• pioids

Teach/Offer opioid storage/disposal § Counsel patients on how to dispose of leftover

• pioids including providing them with a bag to mail it

in when received from our pharmacy § Educate patient and/or family about proper security/storage of opioids and disposal § Education for disposal of medications in the

• utpatient setting

§ Opioid stewardship - opioid recapture/retrieval at

• rtho surgical f/u appt, bring in unused medication to

f/u appt

Texas Prescription Monitoring Program (PMP)

▪ PMP AWARxE

§ An electronic database used to collect and monitor prescription data for all controlled substances dispensed by a pharmacy – In Texas – Or to a Texas resident from a pharmacy located in another state

▪ The PMP also provides a venue for monitoring patient prescription history

for practitioners and the ordering of Schedule II Texas Official Prescription Forms.

▪ Nurses may be listed as a delegate to check the patient’s PMP

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https://www.pharmacy.texas.gov/index.asp

House Bill 2561 (The Sunset Bill)

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§ Currently, pharmacists and prescribers are encouraged to check the PMP to help eliminate duplicate and overprescribing of controlled substances, as well as to obtain critical controlled substance history information. § Passed During 2017 Legislative Session – Beginning September 1, 2019, pharmacists and prescribers (other than a veterinarian) will be required to check the patient’s PMP history before prescribing or dispensing certain controls. This date has now been changed to March 1, 2020. https://texas.pmpaware.net/login

https://www.pharmacy.texas.gov/index.asp Opioids Benzodiazepines

Morphine Hydromorphone Oxycodone Hydrocodone Fentanyl Tramadol Methadone Lorazepam Diazepam Clonazepam Alprazolam Clobazam Midazolam

Carisoprodol Barbituates

Phenobarbital

§ Standard related to Pain Management

▫ LD 04.03.13 – The hospital facilitates and practitioner and

pharmacist access to the Prescription Drug Monitoring Program databases.

Texas Prescription Monitoring Program (PMP)

https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF

Question

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Do you have any opioids in your medicine cabinet at home that are not currently being used? – Yes – No

https://www.polleverywhere.com/multiple_choice_polls/xJeYPQO9u2VaLNdsrYRS8?preview=true&contro ls=none

§ Standard related to Pain Management

▫ PC.0.1.02.07 – The hospital educates the patient and family

• n discharge plans related to pain management including

the following:

• Safe use, storage, and disposal of opioids when

prescribed

Opioid Storage and Disposal

https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF

Sources of Abused Opioids

Ages 12 or Older; 2013 and 2014

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From a friend or relative for free 51% From one doctor 22% Bought from friend or relative 11% Stole from friend or relative 4% Bought from drug dealer or

• ther stranger

5% From more than one doctor 3% Other 4% From a friend or relative for free From one doctor Bought from friend or relative Stole from friend or relative Bought from drug dealer or other stranger From more than one doctor Other SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2013 and 2014.

Medication Disposal

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https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm#household

Household Trash Disposal

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https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm#household

FDA Flush List

The Pendulum Effect

§ The theory holding that trends in culture, politics, medicine, etc. tend to swing back and forth between opposite extremes.

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https://kerririchardson.com/the-pendulum-principle/

Outcomes & Impact

Better data, better decisions

Assessment Workgroup

Lisa Davenport MSN BS RN RNC-NIC Corrie Chumpitazi MD MS

Pain Assessment Team

Our Journey…

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Therapeutic Duplication – Pharmacy

• Citation during 2017 JC Survey

▫ PC.01.02.07 – The hospital assess and manages the patient’s pain.

• EP3: The hospital reassess and responds to the patient’s pain, passed on its

reassessment criteria.

• Tracer Findings:

▫ During a tracer, it was noted that the organization did not conduct a pain reassessment

within the time frame as per the pain policy for the organization.

▫ During a tracer, it was noted that Fentanyl was given for pain and the patient was not

reassessed per organizational policy.

▫ During a tracer, it was noted that a pain assessment was not conducted as required by

• rganizational policy.

▫ Hycet was ordered for pain. There was no associated assessment or reassessment of

pain associated with the medication administration as required by organizational policy.

Therapeutic Duplication – Pharmacy

• Citation during 2017 JC Survey

– MM.04.01.01 – Medication Orders are clear and accurate.

▫ EP 13 The hospital implements its policies for medication orders.

• Tracer Findings:

– There was an oral and IV narcotic ordered for a post-operative patient. Both were ordered for pain and there was no further guidance as to which medication to use. This is an example of therapeutic duplication which is not in accordance with the organization’s therapeutic duplication policy. – There was an order for Fentanyl for pain or sedation. The order was not clarified with the prescriber. – There was an order for diazepam rectal gel and Midazolam injection as needed for seizures. The

• rder did not indicate the parameters for administration of either medication.

– During tracer activities during record review, it was noted that two medications were written for the same indication without differentiation as to when each should be used in multiple records.

Identified Gaps per JC Citation

• No policy existed to guide the nursing staff
• n which pain scale to use based on age,

sedation status and cognitive status

• How are the pain score results currently

used?

• How do the current scales in use translate

to the clinical picture of the patient?

• Are we using the most current evidenced

based scales for our different populations and age groups?

Pain Assessment Care Process Team Goals

▪ To adopt the latest EBP Pain tools for

usage at TCH

▪ To support staff and patients by way of a

policy to guide pain assessment and reassessment at Texas children's

▪ To standardize and guide the usage of

pain tools based upon age & Cognitive status

▪ To leverage technology to improve

compliance for pain assessment and reassessment

Pain Assessment Care Process Team

§ Pain Assessment – Self report is the gold standard – Healthcare providers and parents universally underestimate pain

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Pain Assessment Care Process Team

§ How do we use pain assessments? – For symptom evaluation and assessment – To direct treatment decisions – To indicate efficacy of treatment

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FIRST THINGS FIRST….

Policy Creation: Pain Assessment and Reassessment

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Sept 2018 § Multi-Disciplinary group began work November 2018 § Policy completed Spring 2019 § Education implementation § EBOC Review for EBP to validate current pain tools § Survey of pain projects happening at TCH

Pain Assessment and Reassessment Policy

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New policy includes:

§ Frequency of pain assessment/reassessment § In depth information about each pain tool and it’s recommended population § Stratification of pain by scale § Documentation guidelines § Patient/caregiver education guidelines

Pain Assessment Scales at Texas Children’s

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Pain Scale Age Range (if applicable) Special Conditions (if applicable) Range of Scores PIPP (Premature Infant Pain Protocol)

≤ 37 weeks PMA

N/A 0-21 CRIES

≥ 38 weeks PMA

N/A 0-10 NIPS

<1 year old ( Not available in every area)

N/A 0-7 FACES

≥ 3 years developmentally

N/A 0-10 FLACC

N/A

For use in developmentally appropriate patients (who may or may not be sedated) or sleeping patients. 0-10 r-FLACC

N/A

For use in documented cognitively impaired patients. 0-10 Numeric

10 years of age and older

The child must be able to understand the concept of number

• rder.

0-10 Objective

N/A

For patients who are sedated or otherwise non-verbal (Excluding Women’s Services) 0-10 BPS

Women’s Services Patients

For Women’s Services patient population who are mechanically ventilated. 3-12

Pain Reassessment Frequency For scheduled or PRN Medications

30 minutes following the administration of an intravenous(iv), intramuscular(im) and subcutaneous(sq) analgesic

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60 minutes following non- pharmacologic interventions ***This is a new practice***

60 minutes following the

administration

• f an oral analgesic

Question

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True or False. If a pain reassessment is conducted 1 minute past the 30 or 60 minute requirement, it would be considered non-compliant from The Joint Commission.

Outcomes & Impact

Better data, better decisions

Pain Treatment Workgroup

Melody Hellsten, DNP, APRN, PPCNP-BC, CHPPN Joy Hesselgrave, MSN, RN, CPON, CHPPN

Sources of Pain During Health Care Encounters – Needle Stick Procedures

Negative Two nurses couldn't get a vein [on 6mo baby] to draw blood and tried on both hands and kept sticking him and sticking him over and over, they kept discussing that they couldn't find a vein but kept trying. My son cried blood wrenching screams but they proceeded to keep digging for a vein…..! His fingers are purple today and he cries when he squeezes our finger. Positive They finally made the call to have […]come down with an ultrasound to find a vein. She was extremely caring, took her time and was very thorough with keeping everything sterile and actually cared enough to get sugar water to give to my son to ease the pain of the needle. Negative The first two nurses should [not] be employed at a children's hospital. They had no regard for the pain they were inflicting

• n my son. The nurse was wiggling the needle in his arm because they couldn't find a vein.

Positive The second round of nurses were amazing. They were attentive. One of the nurses even sang to him to try to calm him while they were drawing blood.

Treatment Team Focus

Primary Aim: Increase use of comfort techniques by 50% in children undergoing needle procedures at Texas Children’s campuses by July 2020 – Update the procedural pain protocol – Identify what the current practice is for managing needle stick pain (staff survey and parent feedback) – Ensure procedural pain protocol imbedded in all order templates

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Question

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Have you used the procedural pain protocol for a needle stick procedure? – Yes – No

Update the Procedural Pain Protocol

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Evidence in Practice

§ Children’s Comfort Promise - Minnesota Children’s § Reduce needle pain in children § Focused on 4 interventions:

• For children of 36 weeks corrected gestational age and older, use

4% lidocaine cream or j-tip as topical anesthetics

• Sucrose or breastfeeding for infants 0-12 months
• Comfort positioning
• Age-appropriate distraction
• With all 4 able to improve patient’s experience

(Friedrichsdorf, et al 2018)

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Be Sweet to Babies – Children’s Hospital of Eastern Ontario

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Distraction with IV Start

Non-Pharmacologic Pain Management

§ Breastfeeding during immunizations for infants § Sucrose for infants § Parental presence § Visualization/guided imagery § Deep breathing § Heat/Cold § Positioning § Meditation § Hypnosis § Massage § Aromatherapy § Acupuncture/acupressure § Music therapy § Pet therapy

Immobilization of torso and extremities in a supportive, non-threatening manner Access to the procedure site Child’s Perspective – Use less, non-threatening words (poke vs. stick/needle, hug vs. hold you down) – Support positive coping by allowing child to watch, look away, engage in diversionary activities (counting, singing, breathing or distraction toys)

Other Pharmaceutical Options at TCH

• Buffered lidocaine prior to IV start
• L-M-X cream
• Pain Ease
• Zingo
• Sucrose

Buzzy Bee

Exploring Shot Blocker and J-Tip

https://www.bionix.com/medicaltech/product/shotblocker/

It Doesn’t Have to Hurt!!

Tamara DuBose, MSN, RN Dionne Walker, MSN, RNC-OB

Patient and Family Engagement Workgroup

The background…

Texas Children’s Hospital is committed to making our patients as comfortable as possible during the treatment process Although some level of pain or discomfort may be expected during hospitalization, our care is designed to minimize discomfort while encouraging optimal function We want to encourage open communication and partnership between patients and families and the healthcare team which is critical to maximizing comfort and the ability to perform daily activities

The background, continued…

The PFEE Workgroup reviewed all Press Ganey comments regarding pain Comment Categorizations § Education re: pain § Procedural pain § Pain med § MD/Staff communication re: pain § MD/Staff response and concern for pain § Pain assessment § Treatment of pain § Other (please specify in your notes)

22% 78%

Comments Related to Pain received date: Oct '18-Jan '19

positive negative

Patient Experience Data Overview

75 41 25 20 19 14 7 3 1 19 14 18 1 3 3 2 2 10 20 30 40 50 60 70 80 M D / s t a f f c

• n

c e r n f

• r

p a i n t r e a t m e n t

• f

p a i n p r

• c

e d u r a l p a i n p a i n a s s e s s m e n t p a i n m e d i c a t i

• n

e d u c a t i

• n

/ e x p e c t a t i

• n

r e : p a i n M D / s t a f f c

• m

m u n i c a t i

• n

r e : p a i n M D / s t a f f a c c i d e n t / i n j u r y i n f l i c t e d p a i n

• t

h e r

All Pain Comment Categorization received date: Oct '18-Jan '19

negative positive

Patient Experience Data, continued…

Reviewed current system-wide Press Ganey data to determine potential areas of opportunity (February 2019)

The background, continued…

Aim: To develop a comfort goal implementation plan and education curriculum for 3 inpatient nursing units by May 1, 2019.

• Team decision to model PFW’s use of comfort goal to

guide pediatric pain management (March 2019)

• Reviewed literature to support the implementation of

a comfort goal in the pediatric setting (March 2019)

• Identified areas to perform Comfort Goal PDSA

cycles (April 2019)

Implementation

To implement the use of a “Comfort Goal” in the pediatric setting as part of pain assessment/management Comfort Goal: A targeted pain rating that allows the patient to perform activities of daily living and other essential activities (I.e. repositioning, ambulating, turn, cough, and deep breathing) with minimal discomfort The Comfort Goal will consist of: – Pain Goal – Functional Goal

Implementation continued…

The Comfort Goal should be initiated upon admission with the first pain assessment but must be completed within 24 hours of admission to a unit The Comfort Goal is ongoing and can be revised at any time based on patient/family needs

Point of Care Survey & Patient Education

Pilot Units & Project Timeline

Pilot Units

• Hematology Oncology Unit
• Trauma/Surgery/Orthopedic Unit

Timeline

• September 2019: Partner with frontline nursing staff

(Unit-based QPC & Unit Charge Nurses)

• October 2019: Pre-implementation data collection for

2 weeks (Pilot Go Live Date – immediately following data collection)

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Question

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The goal of the care team is to:

• A. Create a pain-free environment
• B. Minimize pain
• C. Avoid painful procedures

Pearls for Practice

• Educate patient and families on opioid use and proper disposal
• Use appropriate pain scale to assess pain
• Pain is what the patient says it is
• Review pain policy and assessment/reassessment parameters
• Utilize the procedural pain protocol including non-pharmacologic

measures

• Engage patients and families in their pain treatment plan

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Question

What tool from this presentation will you use in your practice?

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QUESTIONS