carrie a. brunson, msn, aprn, acns-bc, ap-pmn; anne m ...aspmn.org/documents/2017 conference...

Carrie A. Brunson, MSN, APRN, ACNS-BC, AP-PMN;Anne M. Smith, MSN, RN-BC;

Lisa G. Guthrie, MSN, FNP-BC;Janane Hanna, RN, MSN, AOCNS;Pamela Beacham, MSN, CCRN-K;

Tamera L. Brown, MS, RN, ACNS-BC, CWOCN;Valerie Gillis, MSN, RN, CPAN;

Michelle Nelson, MA, CNS-BC, RN-BC

DisclosuresCarrie A. Brunson, MSN, RN-BC, APRN, ACNS-BC, AP-PMN

Speakers Bureau Mallinkrodt Pharmaceuticals Owner Pinnacle Pain Consulting

Pamela Beacham, MSN, CCRN-K; Speakers Bureau Mallinkrodt Pharmaceuticals

The Following Presenters Have No Conflict of Interest to Disclose: Anne M. Smith, MSN, RN-BC Lisa G. Guthrie, MSN, FNP-BCJanane Hanna, RN, MSN, AOCNSTamera L. Brown, MS, RN, ACNS-BC, CWOCNValerie Gillis, MSN, RN, CPANMichelle Nelson, MA, CNS-BC, RN-BC

ASPMN Conference Sept. 15, 2017 Session 4E 2

Carrie A. Brunson, MSN, APRN, ACNS-BC, AP-PMN

Describe the impetus for the formation of the ASPMN Pain Outcome

Metrics Task Force


Throughout the end of 2013 and in early 2014, an increasing number of questions were posed to the American Society for Pain Management Nursing (ASPMN) Listserv about

the existence and composition of pain management services.


The work of this task force began with one question

posed by a member, Susan White on

February 19, 2014

This Question Spurred a Tremendous Response from our ASPMN Listserv Membership


Received ASPMN BOD Support


Quality Pain Care and Pain Hospital Consumer Assessment of Healthcare Providers and

Systems (HCAHPS) Scores

HCAHPS Pain Scores are one of eight Patient ExperienceDimension Scores which effect the Total Performance Scoreused to calculate the Medicare Incentive Program known asValue Based Purchasing

Some studies suggest pain management is highly correlatedwith overall satisfaction with the hospital (0.84 correlationcoefficient); Patient Experience Scores represent 30% ofTotal Performance Score (Gupta, 2009).

Therefore, high patient satisfaction with pain managementimpacts the hospitals Medicare reimbursement


The Impact of HCAHPS and Value Based Purchasing on Pain Management Services and Pain Specialists

The Affordable Care Act of 2010 established the Hospital Value Based Purchasing Program, which applies to payments beginning in Fiscal Year (FY) 2013 and affects payment for inpatient stays in more than 3,000 hospitals across the country.

Under the Hospital VBP Program, Medicare makes incentive payments to hospitals based on either: How well they perform on each measure; or How much they improve their performance on each measure

compared to their performance during a baseline period

CMS assesses each measure using an achievement threshold (minimum level of performance) or National Benchmark obtained from baseline data

Program began in October of 2012 with significant financial impact to participating hospitals based on performance


Safe and Effective Quality Pain Management

High Patient Satisfaction Scores with Pain

Management


Pain Outcome Metrics Task Force Established in 2014

Charter“To articulate outcomes of pain management nursing influence

that are or are not associated with HCAHPs, to share best

practices from the group as to what has been effective in

moving the HCAHPs scores up, to find ways to measure our

profession, Pain Management Nursing, and our contribution

to Healthcare”


Prioritized Work Of Task Force The task force identified three outcomes:

1). To articulate the outcomes of pain management nursing influence that are or are not associated with HCAHPS

2). To share best practices from the group of pain management expert nurses as to what has been effective in improving the HCAHPS scores

3). To find ways to measure our profession, Pain Management Nursing and our contribution to healthcare


Anne M. Smith, MSN, RN-BC

Describe the process of literature review for the Pain Outcome Metrics

Task Force Project


CINAHL SEARCH Volunteers either enlisted the assistance of an

institutional librarian or performed the literature search on their own.

One example: CINAHL only with following: (MM "Pain+" AND MH "Nursing Role") OR (MM "Pain+" AND MH "Change Management") OR (pain N3 resource N3 nurs*),Restricted to English, (MM= major subject heading, MH= subject heading, N3= within 3 words)

Yielded 43 articles


Literature Review Each POMTF member given an assignment of articles to

read, review, critique and fill out supplied literature review templates

Areas of interest when reviewing articles: Study population/sample Best practices identified Correlations between pain satisfaction scores and best

practices Barriers cited to pain management Any additional comments or findings of interest If article about PRN role noted team membership, meeting

arrangement, certification, education, organizational resources to support role, barriers cited and outcomes measured, if available


Literature Review Articles were further divided into categories/sphere of

influence:

Across healthcare

At the organizational level

Or, patient level


Janane Hanna, RN, MSN, AOCNS

Describe the findings of literature review for the Pain Outcome Metrics

Task Force Project


Barriers to Pain Management Complex nature of the subjective pain experience

Pain often co-exists or viewed along with suffering, anxiety, depression and quality of life factors

Lack of fundamental knowledge and expertise related to pain management

Lack of assessment

Unavailability and/or infrequent use of non-pharmacological interventions

Frequent staff turnover

Delaying pain management until diagnosis is made

Fear of addiction and intolerable side effects


Barriers to Pain Management-cont. Communication barriers

Cultural barriers

Patients expectations & reluctance to report pain

Healthcare staff perception, attitude & misconceptions

Non-cohesiveness of the healthcare team

Resistance to change

Lack of administrative support

Lack of patient/family education about pain management

Lack of pain education programs within institutions


Literature Findings Tools used to assess pain structure or outcomes:

American Pain Society Pain Outcome Questionnaire –Revised (APS-POQ-R)

Pain Care Quality Survey (Pain CQ)

Best practices linked to

Pain scores (NDNQI)

Patient satisfaction


Literature Review Summary

There is limited evidence and thus limited knowledge of the quality measurement related to structure, process and outcomes of pain management.

There is a need for further research on pain management indicators that directly influence pain outcomes because of the high importance currently placed with reimbursement tied to pain management patient satisfaction.


Tamara L. Brown, MS, RN, ACNS-BC, CWOCN

Describe the methodology used to obtain qualitative

and quantitative information from members of the

ASPMN Listserv


Background In 2014 there was a trend of

increasing questions posted to the American Society for Pain Management Nursing (ASPMN) Listserv about pain management services.

An initial survey was presented to the member list.

Nearly seventy (18%) of the approximately 376 members of the ASPMN responded. We knew we should take this further.


Methods


September 2014. The first meeting of the Pain Outcome Management Task Force (POMTF) was held.

The group began to prioritize activities and developed a Survey Monkey inquiry.

Final approval of the survey was granted by the BOD and the final survey was distributed.

The POMTF then began regular teleconference meetings to discuss the survey results and next steps.

Methods The team decided to develop

two sets of interview questions to be presented at the ASPMN National Conference in 2015.

This was done for the conference attendees who met the criteria as either being a: 1). Dedicated Pain

Management Nurse (PMN) 2). Having Pain Resource

Nurse (PRNs) or Pain Champions at their organization.


Methods On November 4, 2015,

members of ASPMN who were Pain Resource Nurses and Pain Management Nurses were asked to participate in an interview about their role.

In March 2016, results were obtained and then divided up between task force members to summarize and delineate common themes.


Lisa G. Guthrie, MSN, FNP-BC

Outline the results of the initial Pain Outcome

Metrics Survey


Design This was a qualitative

review using surveys via Survey Monkey.

The initial response to the first survey was 7%. The decision was made to return to the initial data from the first survey query and reconsider the survey questions.


Initial Data

ASPMN Conference Sept. 15, 2017 Session 4E28

Initial Data


Does Your Organization Have a Dedicated Pain Team?


HCAHPS Reporting Questions to Identify

Organizations with Best Practice in Pain


HCAHPS Frequency Distribution from Respondents


Comparison of Organizations Reporting Bed Size, Acute Pain Service, Pain Resource Nurse Program and Composite Scores


Frequency of Metrics and Measures Collected related to Quality Pain Management which are not associated

with HCAHPS scores


Qualitative Survey Sample


The larger project focus remains on ways to articulate outcomes of pain management nursing influence that may or may not be associated with HCAHPs.

Share best practices from the group about what has been effective in moving the HCAHPs scores up

Qualitative Survey Sample This project also aimed to

find ways to measure our profession, how we manage our patient’s pain, and our overall contribution to healthcare.

In March 2016, results were obtained and then divided up between task force members to summarize and delineate common themes.


Michelle Nelson, MA, CNS-BC, RN-BC

Describe the results obtained from the dedicated Pain

Management Nurse Qualitative interview

respondents


“A dedicated Pain Management Nurse (PMN) is a Nurse, or an Advanced Practice Nurse whose only responsibility within the organization is to perform pain consultations or at least 50% of the FTE time is spent performing pain consultations and the other 50% is spent on education, policy and program development activities related to pain management within the organization.”

Pain

Man

agem

ent

Nu

rse Setting

Inpt

Outpt

Both

CertifiedYes

No

Pursuing

No response

Education

MSN

CNP

BSN

• PMN’s were less likely to be directly involved in tracking organizational nursing initiatives to improve pain management

• Less than half were involved with review of HCAHPS scores on pain management• Of those who responded positively they

did not indicate they were responsible for the review

All PMNs had a strong passion for caring for patients with pain but their individual experiences and practices were widely

varied.

0

2

4

6

8

10

Identified aspects of role


Pain

Man

agem

ent

Nu

rse 6

4

0

1

2

3

4

5

6

7

Pain Committee

Yes

No

Pain Committee:

• One of the NPs was recently asked to join• In one organization the CNS was involved in 4 other

hospital committees to represent pain • 3 of the organizations without committees had

dedicated PMNs who were CNSs


Pain

Man

agem

ent

Nu

rse

8

2

0123456789

Pain Resource Nurse

Yes

No

Pain Resource Nurse/Pain Champions:

• One negative response was from a clinic• The 3 CNPs did not appear to be involved with the PRN group• 5 responses indicated that they were actively involved with the group

• 1 was co-chairing• 2 were relatively new groups, 1 of which was being “revived”


Pain

Man

agem

ent

Nu

rse

1

8

1

4

2

0

1

2

3

4

5

6

7

8

9

Yes No Unsure

Competencies

Impact

Outcomes

Competencies/Impact/Outcomes:

• 1 facility was currently working on specific pain management competencies• Many PMNs felt little to no impact of programs for a variety of reasons

• Attrition, too soon in the program• 2 were unsure

• Not all respondents indicated what outcomes they were tracking • Morphine equivalents, 0-10 metrics, pain variances, meeting JC standards


Pamela Beacham, MSN, RN, CCRN-K; CNS

Describe the results obtained from the dedicated Pain

Resource/Pain Champion Nurse qualitative interview

respondents


“A pain resource nurse/champion role (PRN) is an engaged, influential, credible and empowered nurse who functions as a resource, expert, mentor, advocate, liaison, change agent and facilitator of evidence-based pain management practices and knowledge across the area of practice and at the point of care.”

Pain

Res

ou

rce

Nu

rse

Setting

Inpt

Outpt

Pain Certified

Yes

No

Pursuing

Education

AD

BSN

Masters

67728490

0

20

40

60

80

100

HCAHPS

2013

2014

2015

2016

• PRN’s were very aware of the what outcome measures were monitored in their organization and knew what improvements had been made

• PRN’s felt empowered to impact pain care real time at the bedside and felt that this work was both directly and indirectly impacting noted improvements

EMPOWERMENT CHANGES PRACTICE …“I can advocate for patients with the physician. When I call now I feel confident that I know what to ask for on behalf of the patient”

One hospital’s experience..


Pain

Res

ou

rce

Nu

rse

20

8087

100

0

10

20

30

40

50

60

70

80

90

100

Time to First Assessment

2013

2014

2015

2016

Outcomes Measured for Pain Assessment:

• Time to first pain assessment • Frequency and number of pain assessments per shift• Frequency of comprehensive pain assessment data with first pain

assessment each shift and updated with new/different types of pain


Outcomes Measured for Pain Management:

• Reassessment with all PRN analgesia within 60 minutes of intervention• Pain management (PRN analgesics) is within scope of practice, i.e., based on

pain intensity per physician order, based on safe opioid administration guidelines

• Use of non-pharmacological pain interventions and reassessment

Pain

Res

ou

rce

Nu

rse


28

57

67

76

0

10

20

30

40

50

60

70

80

Scope of Practice

2013

2014

2015

2016

Outcomes Measured for Patient Engagement:

• Target pain goals set with patient and revaluated regularly• Patient informed of options for pain treatment• Patient education regarding pain assessment methodology

Pain

Res

ou

rce

Nu

rse

40

60

90 90

0

10

20

30

40

50

60

70

80

90

100

PRN Reassessment

2013

2014

2015

2016


Valerie Gillis, MSN, RN, CPAN

Outline the overall Best Practices obtained

throughout all interviews and the literature


Best Practices Identified Implementation of an Advance Practice Nurse Led

Acute Pain Service

Consider providing a pain management fellowship program to direct care nurses who want to advance their pain knowledge and skills with the Acute Pain Service

Implement a pain management program


Best Practices Identified A dedicated Pain Committee with interdisciplinary

representation to evaluate the quality of pain care within your organization

A dedicated pain Clinical Nurse Specialist who has the expertise to evaluate pain management practices in your organization

Implement a mandatory Pain Medication & Opioid Safety course for all RNs, including a pain curriculum that supports multimodal pain management


Best Practices Identified Provide organizational support for programs which

empower nurses to obtain pain management certification, advance their knowledge in pain management and participate in process improvement activities

Incorporate pain education in the New Employee Orientation program and the New Graduate Residency Program

Implementation of some type of communication in the patient’s room for example a “white board” to help communicate to staff and patients.


Best Practices During patient rounding add a question that

addressing pain management

Ensure the discharge patient experience is meaningful that allows time for teaching and questions

Utilize pharmacy colleagues

Implement a questions about pain management in your follow up phone call


Suggested Outcome Measures From Best Practices

Improvement in the clinical performance on Pain CQ Tools:

APS-POQ-R

Pain CQ

Improvement of the patient’s functional status

Improved interprofessional communication and/or coordination of pain care

Decreased use of rescue medications

Review outcomes detailed on slide 34


Best Practices Highlight Nationwide Children’s Hospital

HCAHPS scores reported at 90th Percentile for both pain questions-highest reported from listserv membership

450 Beds; Main Hospital plus offsite clinics

45 Minute New Employee Orientation on Pain Management, Philosophy and Assessment Tools

Implemented 6 Hour Long IV Opioids Class for all RNs

24/7 Acute Pain Service with APN Coverage

Provided review booklet and pre-test

50 Item Test

Required to score 90% or greater


A genuine thank you to Sharon Wrona, DNP, RN-BC,

PNP, PMHS, AP-PMNAdministrative Director Pain &

Palliative Care Services for sharing her organization’s best

practices with POMTF

SummaryPatient Satisfaction is only one outcome

metric to evaluate quality pain management services

More research is required to provide evidence of positive outcomes associated with quality pain management services

All APNs, and nurses working in pain management should participate in activities which contribute to further the body of evidence regarding positive outcomes of our work in pain management


Limitations

Limitations to Survey Design

Response Rate of 7%

Modification of qualitative questions

Would have obtained more robust data with modified questions

Perform a preliminary pilot project and apply learnings to final project

Obtained IRB approval

Pilot data for formal study


Conclusions –Implications for Nursing

In the ever changing health care environment we must find ways to continue to achieve quality outcomes while keeping patients safe and being fiscally responsible

Find one way that you could use the work of this committee and take one small step toward better pain management and improved patient satisfaction


SUMMARY Multiple organizations recommend education and training in pain management

Anesthesia Patient Safety Foundation (2006)

The Joint Commission Sentinel Event Alert #49 (2012)

Institute for Safe Medication Practices (ISMP)

Reducing patient harm from opioids-2007

Urges caution with basal opioid infusions-2009

Multiple State Organizations have now implemented opioid prescribing guidelines which include pain management education and competence


Questions/Comments Any questions or comments for us at this time


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