evidence-based pain management in the ambulatory setting … conference documents...evidence-based...

Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN

ASPMN® 25th National Conference September 18, 2015

0830 – 0930

1

Evidence-Based PainManagement in the Ambulatory Setting

ASPMN® 25th 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 interestor disclosures to report.

Objectives

Outline steps in the evidence-based practiceprocess using the Iowa Model of Evidence-BasedPractice to Promote Quality Care andImplementation Guide.

Describe an EBP project regarding translation ofevidence-based interventions related toneedlestick pain into practice in ambulatorysettings.



0830 – 0930

2

Iowa Model of Evidence-Based Practice to Promote Quality Care

Iowa Model of

Evidence-Based

Practice to Promote

Quality CareTitler et al., 2001

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 & Guidelines

3. Philosophies of Care4. Questions from Institutional

Standards Committee

Triggers

Titler et al., 2001



0830 – 0930

3

Organizational Priority

Titler et al., 2001

Is this Topica PriorityFor the

Organization?

Team

Titler et al., 2001

Evidence

Titler et al., 2001



0830 – 0930

4

Sufficient Research Base

Is Therea SufficientResearch

Base?

Base Practice on OtherTypes of Evidence1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory

No

Titler et al., 2001

Piloting


Base?

Titler et al., 2001

Yes

Adopt Practice Change?

Is Change Appropriate for

Adoption in Practice?

No YesContinue to Evaluate Quality of Care and New Knowledge

Institute the Change in Practice

Monitor and Analyze Structure, Process, and Outcome Data Environment Staff Cost Patient and Family

Disseminate Results

Titler et al., 2001



0830 – 0930

5

Diffusion of Innovations

Illusions about Implementation

Implementation isn’t that difficult

They know what to do

We already provide the best care

They just need to know the evidence

If it works for them, it should work for us

We just need to tell them what to do

We just need to find the one right way toimplement a practice change

Nature of the Innovation –Resistance to Change

Nursing traditions – sacred cows

Lack of authority and support

Landmines

It takes time

Evidence can be overwhelming – access,amount, quality, ability (critique, synthesis,statistics, etc.)



0830 – 0930

6

Diffusion is theprocess by which aninnovation iscommunicatedthrough certainchannels over timeamong the membersof a social system

Diffusion Theory – Rogers

Rogers, 2003

Diffusion Rate100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Pe

rcen

t o

f A

do

pti

on

Innovation I

Later Adopters

Innovation II

Time

Adopters

Innovation III

Adopters

Earlier

Rogers, 2003

Diffusion Model –Innovation-Decision Process

I.Knowledge

II.Persuasion

III.Decision

IV.Implementation

V.Confirmation

AwarenessAwareness

& Attitude Change

Awareness, Attitude &

Behavior Change

Passive Active Interactive

Logan & Graham, 1998; Rogers, 2003; Veniegas et al., 2009



0830 – 0930

7

Implementation Strategies

EBP Implementation Model

Laura Cullen, DNP, RN, FAANSusan Adams, PhD, RN

Cullen, L., & Adams, S. (2012). Planning for implementation of evidence-based practice. Journal of Nursing Administration, 42(4), 222-230.

I.Create

Awareness & Interest

II.Build

Knowledge & Commitment

III.PromoteAction & Adoption

IV.Pursue

Integration & Sustained Use

Implementation Phases

Cullen & Adams, 2012



0830 – 0930

8

Clinicians

Organizational Leaders

Key Stakeholders

Social System

Organizational Context

Implementation Target Groups


ImplementationStrategies for

Evidence-Based Practice


Evidence-Based Strategies

Empirical Evidence in Healthcare* Audit and feedback

Little Evidence in Healthcare Unit posters E-mail broadcasts




0830 – 0930

9

Phase I:

Goals What are the positives

about the EBP? Think of this as

marketing the EBP. Should be fun and eye

catching.

Strategies Highlight advantage

Highlight compatibility

Sound bites

Create Awareness & Interest


Phase II:Build Knowledge &Commitment

Goals How do clinicians within

a discipline like tolearn?

Build upon the naturaltendency for cliniciansto learn from eachother.

Keep an eye towardbuilding the EBP intothe system to make iteasy to do it right.

Strategies Education Change agents Educational outreach or

academic detailing Gap assessment/gap

analysis Local adaptation and

simplify Action plan


Phase III:Promote Action andAdoption

Goals Use highly interactive

and personalapproaches.

Demonstrate with returndemonstration andreinforcement.

Expand upon contextfocused strategies.

Strategies Educational

outreach/academicdetailing

Try the practice change Change agents Audit key indicators Actionable and timely

data feedback Report into quality

improvement program




0830 – 0930

10

Phase IV:Pursue Integrationand Sustained Use

Goals Think about booster

shots or periodic reinforcement.

Build toward EBPbecoming the norm or standard way to practice.

Building EBP into thesystem is critical to help clinicians.

Strategies Peer influence Audit and feedback Report into quality

improvement program


Implementation in Action…

http://www.crucialskills.com/2009/09/all-washed-up/

Ambulatory Evidence-Based

Pain Management



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


Conduct Research

Titler et al., 2001

Iowa Model (cont.)



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

Immunization Experience…

http://tedmed.com/talks/show?id=299421

Synthesis of Evidence (cont.)

Evidence-based interventions available: Topical anesthetic creams Breastfeeding Distraction (child-, clinician-, or parent-led) Sucrose solution Patient positioning Tactile stimulation Breathing exercises Buzzy® device Bacteriostatic normal saline Vapocoolant spray

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



0830 – 0930

13

Assemble Relevant Research & Related Literature





Conduct Research

Iowa Model (cont.)

Titler et al., 2001

Practice Change

Adult and pediatric patients in ambulatory clinics Injections/immunizations, blood draws, or IV starts

Evidence-based pharmacologic, physical, andpsychological interventions must be routinelyoffered to patients/caregivers

Focus: Topical anesthetic creams Buzzy® device Bacteriostatic normal saline Vapocoolant spray


I.Create

Awareness & Interest

II.Build

Knowledge & Commitment

III.Promote Action & Adoption

IV.Pursue

Integration & Sustained Use

• Highlight advantages oranticipated impact

• Highlight compatibility• Slogans & logos• Divisional newsletter• Unit inservices• Distribute key evidence• Posters and postings/fliers• Publicize new equipment

• Ambulatory nursing pain committee formed

• Education• Pocket guides• Change agents• Clinician input• Local adaptation & simplify• Match practice change with

resources & equipment• Troubleshoot use/application• Inform organizational leaders• Action plan

• Reminders or practice prompts

• Skill competence• Give evaluation results to

colleagues• Try the practice change• Role model• Documentation• Patient decision aides• Report at shared governance

committees• Link to patient/family needs

& organizational priorities• Divisional orientation

• Peer influence• Revise policy, procedure or

protocol• Project responsibility in unit

or organizational committee• Present in educational

programs

Implementation Strategies



0830 – 0930

14

Specific Strategies

Web-based training (PPT) Staff Education Committee approval

Total # completed (n=1124)

Hands-on pain competency station Super-Users (n=22)

Regular attendees (n=502)

Pocket Card – Adults

Pocket Card – Pediatrics



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”

MA Competency Checklist before able

to administer; Obtained from

Pharmacy

Additional resources: Aircare – Adult Aircare – Pediatric & Neonatal Emergency Department Charge Nurse Pediatric Vascular Access Nurse Pagers 1131/1136 Pager 3210 Phone 3-6261 Pager 4213



0830 – 0930

16

Evaluation – Staff Questionnaire

Response Rate Pre-Implementation – 26.5% (n=195/735)

Post-Implementation – 29.2% (n=203/696)

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!”



0830 – 0930

17

Conclusions

Staff knowledge improved & perceptions changed

Ongoing re-infusion will be needed forsustainability and integration

Positive outcome – materials revised ordeveloped being used by other areas within thehospital

Continue to EvaluateQuality of Care andNew Knowledge

Institute the Change in Practice

Monitor and Analyze Structure,Process, and Outcome Data

- Environment- Staff- Cost- Patient and Family

Disseminate Results

Iowa Model (cont.)

Titler et al., 2001

Next Steps

Incorporated content: Divisional orientation

Annual competencies

Purchased items and developed pain toolkits foreach clinic

Obtained funding for small freezers – Buzzy® gelwings

CE program and Grand Rounds – October 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!

Acknowledgement

Questions/Comments

[email protected]@uiowa.edu

[email protected]@uiowa.edu

References

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.



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.



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


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


Base?



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

DO NOT REPRODUCE WITHOUT PERMISSION Revised April 1998 © UIHC

= 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

Education (e.g., live, virtual orcomputer-based)*

Pocket guides Link practice change & power

holder/stakeholder priorities* Change agents (e.g., change

champion*, core group*,opinion leader*, thoughtleader, etc.)

Educational outreach oracademic detailing*

Integrate practice change withother EBP protocols*

Disseminate credibleevidence with clearimplications for practice*

Make impact observable* Gap assessment/gap

analysis* Clinician input* Local adaptation* & simplify* Focus groups for planning

change* Match practice change with

resources & equipment Resource manual or materials

(i.e., electronic or hard copy) Case studies

Educationaloutreach/academic detailing*

Reminders or practiceprompts*

Demonstrate workflow ordecision algorithm

Resource materials and quickreference guides

Skill competence* Give evaluation results to

colleagues* Incentives* Try the practice change* Multidisciplinary discussion &

troubleshooting “Elevator speech” Data collection by clinicians Report progress & updates Change agents (e.g., change

champion*, core group*,opinion leader*, thoughtleader, etc.)

Role model* Troubleshooting at the point

of care/bedside Provide recognition at the

point of care *

Celebrate local unit progress* Individualize data feedback* Public recognition* Personalize the messages to

staff (e.g., reduces work,reduces infection exposure,etc.) based on actualimprovement data

Share protocol revisions withclinician that are based onfeedback from clinicians,patient or family

Peer influence Update practice reminders

Build

ing

Orga

niza

tiona

l Sys

tem

Sup

port

Knowledge broker(s) Senior executives

announcements Publicize new equipment

Teamwork* Troubleshoot use/application* Benchmark data* Inform organizational leaders* Report within organizational

infrastructure* Action plan* Report to senior leaders

Audit key indicators* Actionable and timely data

feedback* Non-punitive discussion of

results* Checklist* Documentation* Standing orders* Patient reminders* Patient decision aides* Rounding by unit &

organizational leadership* Report into quality

improvement program* Report to senior leaders Action plan* Link to patient/family needs &

organizational priorities Unit orientation Individual performance

evaluation

Audit and feedback* Report to senior leaders* Report into quality

improvement program* Revise policy, procedure or

protocol* Competency metric for

discontinuing training Project responsibility in unit or

organizational committee Strategic plan* Trend results* Present in educational

programs Annual report Financial incentives* Individual performance

evaluation

* = Implementation strategy is supported by at least some empirical evidence in healthcare

DO NOT REPRODUCE WITHOUT PERMISSION Requests to: Department of Nursing

[email protected] The University of Iowa Hospitals and Clinics

Iowa City, IA 52242-1009 ©University of Iowa Hospitals and Clinics / Laura Cullen, MA, RN, FAAN

Build Knowledge & Commitment

Promote Action & Adoption

Pursue Integration & Sustained Use

Create Awareness & Interest

evidence-based pain management in the ambulatory setting … conference documents...evidence-based...

Documents