10/1/2015

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Improving HCAHPS Pain Scores

Kathy Baldwin, BS Pharm, MA, 

Pharm D, BCPS

Disclosure

• I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation

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Objectives

Technicians

• Discuss payer for performance strategies

• Describe drugs used to treat pain

• Identify side effects of drugs used to treat pain

Pharmacists 

• Describe drug therapy interventions to improve HCAHPS pain scores

• Identify key components to a thorough pain assessment 

• Develop strategies to prevent side effects of pain meds and reduce LOS 

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Payer for Performance 

• Established by National Quality Forum (NQF)

• Attempt to standardize quality measures/reporting

• Measure patients’ perspective 

• Allow for public reporting

• Enhance public accountability 

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Patient Experience of Care

• Hospital Consumer Assessment of Healthcare Providers and Suppliers (HCAHPS)

• Consistency Score– Compares patient experience of care rate to that of all hospitals

• HCAHPS score + HCAHPS consistency score = Patient experience of care score

Incentive Payment OCT 2012

Funded from 1.5% of Diagnosis‐Related Group payment

FY 2013 : 1 % withheld 

FY 2015:  1.5% withheld

FY 2016: 1.75% FY

FY 2017 and thereafter : 2% withheld

May receive net increase or decrease in Medicare payment

Will depend on total performance score

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Hospital Value‐Bases Purchasing Program

• Clinical Process of Care – 20%

• Patient Experience of Care – 30%

• Outcome – 30% 

• Efficiency – 20% 

Patient Experience of Care

• Nurse Communication

• Doctor Communication

• Hospital Staff Responsiveness

• Pain Management 

• Medicine Communication

• Hospital Cleanliness and Quietness

• Discharge Information

• Overall Hospital Rating

HCAHPS Pain Scores

Pain Questions (2)

Did everything help my pain

My pain was well controlled 

3 scores are generated

Overall pain score 

Did everything to help my pain

My pain was well controlled

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Pharmacist Therapy Management

% Hospitals Where Pharmacists Manage Specific Therapy

Anticoagulation 69.2

Pain Management 11.6

Nutrition 43.2

Renally Dosed Antibiotics 79.7

Aminoglycosides 80

Vancomycin 89.4

Antibiotic Selection 21

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N=413 hospitals (2013)

Am J Health-Syst Pharm. 2014; 71:924-42

Role of the Pharmacist 

Personal experience

Medication Therapy 

Protocols

Eforcse ®

Began reading and attending pain conferences

Experts in drug therapy monitoring

Began seeing post NS/orthopedic patients 

Joined the health system Pain Team: educate

New Pain Service  11

Weaver 9

Neurosurgical Patients

Multi‐level fusions

Hardware to bone

Acute on chronic pain 

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Neurosurgery Scores Sept 2013‐August 2014

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Neurosurgery Scores April 2014‐March 2015  (n=351)

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98

77.5

18.7

3.40.4

0

10

20

30

40

50

60

70

80

90

100

Percentile Always Usually Sometimes Never

Percentage

W9 ‐ Pain Management93

68.4

25.9

4.8

0.9

0

10

20

30

40

50

60

70

80

90

100

Percentile Always Usually Sometimes Never

Percentage

W9 ‐ Pain Well Controlled

99

86.6

11.4

20

0

10

20

30

40

50

60

70

80

90

100

Percentile Always Usually Sometimes Never

Percentage

W9 ‐ Staff Does Everything to Help With Pain

Patient Assessment is Critical

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Case

66 YOF s/p spine surgery

Recommend and implement multimodal PO plan

Patient didn’t buy in

Refused the plan

Discussed plan with patient

Based on prior experiences she received IV opiates x 72 hours and didn’t want PO meds

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Case

Patient hospitalized for non pain issue

Suffers from headaches routinely

Develops headache while in hospital hospital

Headache for 2 days

Seen by neurologists, IM 

Pharmacist consulted

What do you want for your headache?

Ibuprofen, caffeine, lidocaine pach, feverfew

Takes these at home / they work20

Case post op withdrawal

• 38 YOM s/p spine surgery

• Opiate use on med reconciliation form reported as: Percocet “prn” pain***– Ignored true baseline opiate use

– Used our protocol:• Percocet 5 q 4 hours prn pain

• May repeat x 1 tab in 1 hour if pain unrelieved

• Patient in 10/10 pain, thrashing, crying

• BP 180/120 HR 120 bpm

• Rx plan post op ?

Patient History

Patient smokes 1 PPD: Consider nicotine replacement unless CI

Patient drinks 8 beers/day: ETOH w/d protocol

Patient smokes marijuana, cocaine, heroin* etc*

Good luck 

Patient takes SSRI/drugs associated with w/d at home: resume

Patient takes tramadol at home:  We reduce dose by 50% 

Patient drinks caffeine: reduce dose and taper 

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Case

• 62 YOM severe pain 10/10

• POD 4 spine surgery

• What do I need to know to manage his pain?

– What hurts?

– Large toe “I’m having a gout flare”

• Does this patient require opiates? 23

Case

• 82 YOF s/p complicated spine surgery– Dementia and communication issues

• Admitted to ICU

• POD 12 and c/o severe pain

• What do I need to know to assess pain?

• What hurts?– Chronic arthritis exacerbated by laying in bed

• Received acetaminophen

• Good pain control24

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Quantitative Assessment

Quantitative (Severity)

Cognitively Intact Communicative patient

1‐10 pain scale score 

Non Cognitively Intact 

Wong Baker Faces Scale

FLACC score/Pain AD scale25

Incorrect Assessment Tools

• 75 YOM spine surgery patient

• 12 hours surgery / anesthesia

• Post op non‐communicate delirium patient

• RN asks patient “do you hurt”

– Patient says NO or doesn’t answer

– No pain medication x 6 hours post op

• New onset atrial fib with RVR

• Transferred to N‐ICU

• Receives no pain medication 26

Pharmacy Consult

• CAM ICU +

• Unable to interact with environment

• Optimize environment

• Dexmetomidine gtt

• IM Olanzepine

• Fentanyl gtt

• IV Methocarbamol

• NO benzos

• NSAID  27

Objective Symptoms of Pain

Objective SIGNS May or May NOT be present

Tachycardia*

Blood Pressure*

Respiratory Rate*

PAD guidelines state do NOT use these parameters in delirium patient 

We find value in the addicted patient not taking heart rate drugs 

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Case

• Delirium x 10 days

• 6 months later

– Exhibits some degree of cognitive impairment at times

– No recollection of time in hospital

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Take Home Message

Pain Assessment Tool MUST be appropriate to patient*

Consider:

Is this patient a good historian?

Should this patient be having pain?

12 hour surgery with hardware

7 level surgical site

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Qualitative Assessment

Baseline opiate use (EFORSCE)

Description, Location

Effective treatment modalities by history

Evaluation of substance withdrawal

Goal Setting

Demonstration

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Anatomical Considerations

3334

The Normal Pain Processing Pathway

3. A signal is sent via the ascending tract to the brain, and perceived as pain

2. Impulses from afferents depolarize dorsal horn neurons, then, extracellular Ca2+ diffuse into neurons causing the release of Pain Associated Neurotransmitters – Glutamate and Substance P

1. Stimulus sensed by the peripheral nerve (ie, skin)

1. Staud R and Rodriguez ME. Nat Clin Pract Rheumatol. 2006;2:90-98.2. Gottschalk A and Smith DS. Am Fam Physician. 2001;63:1979-1984.

4. The descending tract carries modulating impulses back to the dorsal horn

Pain Perceived

Glutamate

Substance P

Pregabalin/gabapentin

TramadolTapentadolDuloxetine

Multi‐Modal Pain Management Rationale Polypharmacy 

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THERAPEUTIC OPTIONS

Mix Pain:Neuropathic and

nociceptive elements

Neuropathic: PeripheralCentral

Nociceptive:SomaticVisceral

TCADs/SNRIAnticonvulsants

TramadolOpioids*** Topicals

AnticonvulsantsTramadolOpioids

NSAID’sAcetaminophen

TramadolOpioids

Muscle relaxers/Anti-spasmotics

Codd EE, Martinez RP, Molino L, Rogers KE, Stone DJ, Tallarida RJ.. Pain 2008;134(3):254-6236

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Neuro‐chemical Basis for Surgical Pain

Cell damage

PGs/Bradykinin

Peptide release

substance P

Vasodilation

Neurogenic edema

Histamine release

Serotonin release*Nor-epinephrinee

GABA

NMDA37

Pain

.

Surgical Siteopiates

Muscle SpasmMethocarbamolBaclofendiazepam

NervePregabalin or GabapentinSNRI or TCADsLidocaine patches/cream

Nerve RootSteroids

Bone/JointNSAIDSAcetaminophen

Subtypes:CancerHeadache* Gout

Cold for Acute Injury

• Including surgical sites 

Opiate Pain Plan

Patient verbalizes 10/10

Hydromorphone* 0. 5mg IV   x 1 

hydromorphone/APAP 7.5 mg q 4 h prn moderate/severe pain first dose NOW

May repeat in  30 minutes and increase to 2 tablets thereafter

Methocarbamol 750 mg po q 4 hours

Pregabalin 75 mg po bid 

Celecoxib 400 mg po x 1 now then bid x 5 days 40

Application

• The role of IV opiates should be reserved for patients– Who cannot tolerate PO

– Patients with severe pain• Who require quick relief (15 minutes or less)

• ORAL opiates should be used for ALL other patients

Predicting and Preventing Side Effects

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Side Effects

.

Itching Certrizine daily prnDiphenhydramine prn

Patent preference*

Nausea/VomitingZofran first PromethazineDrop/haloperidol*Scopalamine patch**

HypotensionFluid bolus*Ephedrine IM*

Respiratory Depression

Bowel Regimen*Senna/Docusate routineMiralax routineMethylnatrexone SC PO day 2 if no prior BM

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Identify patients who are at RISK for respiratory depression and take precautions CapnographyNo long actingHeavy multimodal with rxs known NOT to cause resp depression Limit combs know to cause resp dep

Our Practice PO Patients

If the gut works USE it : Optimize PO pain plan

Lower IV doses : Hydromorphone 0.5 mg IV q 2 h prn 

breakthrough pain unrelieved by PO medication AND PCA

OR 8‐10/10 pain overlapped with PO 

Use PCAs WITHOUT basal along with PO opiates

0.2 mg Hydromorphone PCA q 6 minutes on demand only 

Multimodal drug therapy

IF patient becomes NPO scrap plan and use PCA

With basal UNLESS OSA etc 45

10-15 minutes

Oxycodone/Norco PO peak 30 mins

4 hours3-4 hours

The Peaks associated with IV opiates can cause respiratory depression and euphoria

Lower peaks with oral provide less side effects and less euphoria

Our Practice if NPO 

Use PCA

Opiate tolerant

use basal rate

Opiate naïve/OSA*

capnography

No basal rate

Treat cause of the NPO

N&V 

Procedure: NPO except meds 47

IV bolus duration of action

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Self-Assessment Question

The benefit of oral pain medications over IVpain medications is:

a) 30 minute onset of activity

b) Longer duration of effect

c) Equivalent doses of po yield equal efficacy

d) ALL of the above

d) ALL of the above

Long Acting Opiates

Avoid long term in opiate naïve patients

May be useful short term (1‐4 doses)

Avoid in OSA patients/underdiagnosed OSA patients

Useful in opiate tolerant patients with short acting breakthrough medication

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Equipotent Dosing Charts

• Use them

• Recognize pitfalls

– Pharmacogenomic issues

– Organ system dysfunction

• Renal

• Hepatic 

5152

TABLE I A COMPARISON OF MAJOR ANALGESICS WITH RESPECT TO DOSAGE , AND DURATION; BASED ON SINGLE‐DOSE STUDIES ‐ DOSES REQUIRED MAY BE LOWER WITH REPEATED ADMINISTRATION 

Drug Class IEquianalgesic Doses (mg) Duration of Action in (hours)

Morphine (IV/IM/SC) 10 4‐6

(PO IR) 30‐40 4

(PO CR) * 30‐40 8‐12     MS Contin

(PO SR) ** 20‐60 24:  Avinza

(Rectal) 10 4‐24 

Codeine (IM/SC) 120‐130 4‐6

(PO) 180‐200 4‐6 

Oxycodone (percocet, oxycontin CR, ) (PO) 20‐30 3 hours  

(PO CR) 20‐30 12

Hydrocodone (norco) (PO) 30 4‐6

Hydromorphone (dilaudid)  (IV,IM,SC) 1.5‐2 3‐4 

(PO) 6‐7.5 4‐6

Oxymorphone   (Opana – non‐formulary) Long acting ER and immediate acting 

(PO) See web sight

www.opanaer.com

Drug Class II

Meperidine (Demerol) * (IM,SC) 75‐100 2‐4

(PO) 300 3‐4

Fentanyl (Duragesic) (IV) 0.1 1.5‐2

(TD) See web site 48‐72

Drug Class III

Methadone  (use Up to Date for methadone) (IM, SC) 5‐10 3‐8

(PO) 2.5‐15 + 2‐10 ++

+Dose ratio may increase as the dose of morphine increases

++Increases with repeated dosing***reduce dose by 25% when jumping classes

Medication Equivalent Dosing

Hydromorphone IV 2 mg

Hydromorphone PO 6 mg  

Oxycodone/APAP*  30 mg 

Hydrocodone/APAP*       30 mgLortab, Norco, Vicodin 

Morphine  PO 30 mg  

54www.duragesic.com PI (use available tools)

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Barriers to Pharmacist Pain Interventions

Pharmacist Barriers

Workload*

Assessment

Lack of understanding of anatomy

Lack of training*  

Inappropriate assessment**

Patient factors

pain is subjective,  addiction is rampant

patient fear/bias***

Undiagnosed OSA  55

Order Entry • Are opiates optimized

– Oxycodone 3 hour drug

– Oxycodone with APAP 4 hour drug

– Hydrocodone 4 hour drug

• Is itching a documented side effect of opiates

• Is the patient receiving bowel regimen

• Is the patient having N&V 

• Is patient receiving morphine with poor renal function

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Thank You ! 

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Kathleen.baldwin@bmcjax.com