Exploring the Applicability of the RNAO Best Practice Guidelines for

Exploring the Applicability of the RNAO Best Practice Guidelines for Pain Assessment and Management

in Hip Fracture Patients

November 2008

Exploring the Applicability of the RNAO Best Practice Guidelines for Pain Assessment and Management in Hip Fracture Patients (Nov. 2008) 2

TABLE OF CONTENTS

Executive Summary……………………………………………………………………….……………………….. 3

Acknowledgements ………………………………………………………………………………….……………..10

1.0 INTRODUCTION ……………………………………………………………………………………….. 10

2.0 BACKGROUND ………………………………………………………………………….………………10

3.0 RESEARCH QUESTION AND PROPOSITION ………………………………………………….……. 12

4.0 RESEARCH METHODS ……………………………………………………….…………..…………… 12

Overview ………………………………………………………………………………………………… 12

Adaptation of the RNAO Best Practice Guidelines ……………………………………………….…….. 12

Knowledge to Practice Workshops ………………………………………………………………….…… 13

Qualitative/Quantitative Data Analysis ………………………………………………………….………. 15

5.0 RESULTS …………………………………………………………..…………………………………… 15

Description of the Typical Hip Fracture Patient ………………………………………………………… 16

Current Pain Management Practices ………………………………………………………..…………… 16

a) Pain Assessment ………………………………………………………………………….……… 17

b) Pain Management ………………………………………………………………………….…….. 17

c) Specialized Pain Management Teams/Clinicians ……………………………………….………. 18

d) Communication ………………………………………………………………………..………... 18

How Common was it for Participants to Raise the Topic of Pain? ……………………………………… 19

Applicability and Feasibility of RNAO Best Practice Guidelines …………………………....…………. 19

6.0 DISCUSSION ………………………………………..………………………………………………….. 23

Recommendations for Next Steps ……………………………………………………………………….. 25

Conclusions ………………………………………………………………………..……………………. 26

7.0 REFERENCES …………………………………………………………………….……….…………… 27

APPENDICES …………………………………………………………………………………………………… 33

Appendix A: RNAO Best Practice Guideline Assessment and Treatment of Pain Adaptation ………... 33

Appendix B: Research Team and Community Alliances ……………………………………….……… 35

Appendix C: Facilitator Summary ……………………………………………………………..……….. 37

Appendix D: Financial Disbursement Report ………………………………………………………..…. 39


Exploring the Applicability of the RNAO Best Practice Guidelines

for Pain Assessment and Management

EXECUTIVE SUMMARY

Ryan, D., Saryeddine, T., Watt-Watson, J., Crilly, R., Moir. J., Levy, C., Gibson, M., Kontos, P., Korkola, L., Gagliese, L., McMullan, J., with Research Associates Leslie Soever and Crystal MacKay

Funded by the Canadian Nurses Foundation (Nursing Care Partnership program made possible

by a grant from the Canadian Health Services Research Foundation) Purpose:

The purpose of this project was to explore the applicability of the Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline for Pain Assessment and Management to the hip fracture population transitioning from the last 24 hours of acute care to the first 24 hours of inpatient rehabilitation. Background:

Pain is one of the four most common experiences of patients with hip fracture. In spite of this, the literature suggests that pain is often unrecognized and untreated (Archibald, 2003) for a variety of reasons including fear of administering medications and potential adverse events and myths about how older people experience pain (Forster et al, 2000; Brummel-Smith, 2002; Egbert, 1996; Ardery et al, 2003; McDonald and Hilton, 2001; Adunsky et al, 2002; Forester et al, 2000; Herr 2004). Hip fractures account for approximately 19% of all inpatient rehabilitation cases in Ontario (GTA Rehab Network, 2006; Jaglal et al, 2001). Approach:

The RNAO Best Practice Guidelines were adapted according to an accepted protocol for guideline adaptation published by Ferver et al, 2003 (Guideline Adaptation included in Appendix A). Using a unique facilitation methodology called Build-a-Case (Ryan, 2004), eight focus groups across three sessions with a total of 66 professionals from acute care and inpatient rehabilitation professionals caring for hip fracture patients developed patient cases that reflected their actual practice. The focus groups were then asked to discuss pain management for the population. Emerging themes were recorded and analyzed according to accepted qualitative methods. The focus groups were then provided with either a video or face-to-face presentation of the best practice guidelines, PowerPoint slides and a checklist reflecting the 21 adaptation points from the guideline. After the presentations, the focus group members were asked to reflect on the specific patient case and to complete a questionnaire which contained the 21 points of the guideline adaptation. The participants were asked to indicate the extent to which they believed the point was best practice and the extent to which they believed it was feasible in the practice setting. The research team consisted of psychologists, researchers, rehabilitation professionals, physicians, nurses and gerontologists. One member of the research team was on the authorship team of the pain assessment and treatment guidelines. Two skilled research associates were also retained to ensure consistency and objectivity in the analysis of the transcripts. Findings:

The case was constructed based on qualitative analysis of the transcripts as well as the facilitators recording of characteristics provided by the focus group when they were asked to construct a case of the “typical” hip fracture patient. It is important to note that there were both acute care and inpatient rehabilitation in the focus groups and


providers were asked to focus on the patients that they would typically see. In most of the patient cases that were developed, typical hip fracture patients were characterized as female of average age 83 years. The age range of the patient cases was between 79 and 90 years of age. The typical patients had co-morbidities (e.g. visual difficulties, diabetes, hypertension) and cognitive difficulties or delirium during their hospital stay. All patients in the scenarios lived alone. Most patients had families; however, families did not always live close by and/or did not provide daily support. In many but not all of the focus groups, the issue of pain management was raised unprompted. The emerging themes in the hip fracture cases fell into the categories of describing the hip fracture patient, managing pain, barriers to pain management and acute and rehabilitation processes. The following table shows the sub-themes.

Themes arising from the pre-education pain management discussion Description of a typical patient with hip fracture

Acute care and inpatient rehabilitation processes

Pain management Facilitators and barriers to pain management

• Hip fracture characteristics

• Cognition • Living situation • Effect of language

barrier on pain • Post-operative

delirium • Co-morbidities • Family involvement

• Length of stay • Goal-setting • Rehabilitation criteria • ER process* • Acute care process • Inpatient rehab

process* • Team • Communication • Communication –

internal/external • Factors affecting

discharge destination • Process for transfer to

rehabilitation

• Pain symptoms • Physical effects of pain • Duration of pain • Details of pain • Pain management • Pain measurement • Pain measurement –

trends • Transition from IV to oral

medications • Dosage • Protocol • Perceptions of pain –

healthcare provider • Pain prevention** • Patient education

regarding pain • Frequency of pain

monitoring • Suggestions re guidelines • Concerns re guidelines*

• Barriers – healthcare provider

• Barriers – lack of time • Barriers – understanding

culture • Barriers – access to

specialists • Barriers – transfer issues • Barriers – lack of

education • Barriers – bowel side

effects • Barriers – medication side

effects • Facilitators – senior

management buy-in • Facilitators – clinical

champion • Facilitators – family

involvement • Facilitators – access to

specialists *Additional emergent themes **Non-emergent themes for second phase of focus groups Upon presentation of the guideline adaptation, we learned that the 21 points summarizing the 66 recommendations in the RNAO best practice guideline for pain management were applicable to hip fracture patients. All 21 points were rated by more than 93% of participants as considered best practice. However, when it came to feasibility, three of these items were considered problematic: the parameters required for assessment (#3), the involvement of patients and families in noticing and recording pain (#6) and documenting all pharmalogical interventions on a systematic pain record (#21). The recommendations for assessing pain were not thought to be feasible given the short length of stay typical for this population. In addition, some participants stated that drawing the patient’s and family’s focus to pain would introduce fear and increase the focus on pain that would inhibit the rehabilitation process. In this case, it was felt that the awareness of pain had to be more with the


provider. The following table shows the results of the descriptive and qualitative analysis of transcripts with respect to each of the 21 guidelines.

Summary of findings from the descriptive statistics and transcript analysis for each point in the guideline adaptation

Guideline (point in the adaptation) Agree with

point in adaptation N* (%)

Feel the point is feasible N* (%)

Concerns Suggestions

# 1 – Screen and assess once a day for pain. Reassess after each procedure.

56/58 (97%)

54/58 (95%)

Lack of specificity in the guideline regarding what constitutes or defines a procedure. Frequency of reassessment, for example, is once/day adequate

Provide example of what constitutes a procedure. Include monitoring for pain ‘before’ procedures as well as ‘after’ procedures. Change the terminology from “once a day” to “at least once per shift.”

# 2 – Assess using standardized tools.

58/58 (100%)

51/58 (89%)

Balance between use of standardized tools for formal assessment and informal assessment.

Consider different standardized tools in acute care versus rehab.

# 3 – Parameters of assessment should include the following parameters: location; intensity; medication; precipitating factors; quality of pain; radiation of pain; timing; impact of pain; preferences about management, situational, coping responses, meaning of experience, understanding of disease, psychosocial and spiritual effects; record of interventions; impact of interventions. Validate the assessment with others.

56/57 (98%)

38/56 (68%)

Develop a flow sheet to tick parameters related to pain

# 4 – Unexpected pain should be immediately evaluated.

58/58 (100%)

56/57 (98%)

# 5 – Document and make documentation available to other clinicians.

56/57 (98%)

50/56 (89%)


Guideline (point in the adaptation) Agree with point in adaptation N* (%)



# 6 – Teach patient and family to document pain assessment.

51/55 (93%)

34/56 (61%)

By having patients and/or family record pain logs, there is a potential to inadvertently increase the focus on pain. Some patients may not have the family support to assist with recording on pain logs.

Include standardized questions for families to assist with pain assessment

# 7 – Advocate for changes in treatment plan if pain untreated.

58/58 (100%)

50/56 (89%)

# 8 – Refer patients with chronic pain to a specialist.

57/57 (100%)

43/56 (77%)

Feasibility of dealing with chronic pain due to lack of resources.

# 9 – Establish a pain management plan that includes, at a minimum, the assessment findings, baseline characteristics, physical and psycho-social characteristics, etiology, pharmacological and non-pharmacological strategies, management interventions, current and future primary care treatment plans.

55/57 (96%)

44/56 (79%)

# 10 – Ensure individualized selection of analgesics considering the intensity and type of pain.

58/58 (100%)

54/57 (95%)

Use of word ‘ensure’.

Include the physician as part of the pain management team.

# 11 – Advocate for use of simplest analgesic and least invasive modalities.

57/57 (100%)

54/56 (96%)

Fear of under medication.

Simplest could mean the simplest form of effective medication.

# 12 – Do not use merperidine for the treatment of chronic pain unless for a very brief acute pain situation and do not use it for patients with impaired renal function

48/49 (98%)

44/48 (92%)

# 13 – Administer analgesics on a regular basis.

56/56 (100%)

50/54 (93%)





# 14 – Evaluate efficacy of pain relieve at regular intervals

57/57 (100%)

52/54 (96%)

# 15 – Ensure individuals understand the importance of immediately reporting unrelieved pain.

57/57 (100%)

50/54 (93%)

Include education of patient regarding what would be an expected ‘normal’ course of pain. Engage patients in pain monitoring.

# 16 – Use an equi-analgesic table to ensure equivalency.

49/49 (100%)

36/45 (80%)

# 17 – Advocate for consultation with a pain management expert for complex pain situations.

56/56 (100%)

44/53 (83%)

What constitutes a pain management team.

# 18 – Anticipate and monitor individuals taking opioids for common adverse effects.

56/56 (100%)

52/56 (93%)

Include an extensive education program regarding opioid management and assessment for the health care team.

# 19 – Recognize the difference between drug addiction, tolerance and dependency.

57/57(100%)

47/54 (87%)

# 20 – Anticipate pain that may occur during treatments. Recognize that anxiolytics and sedatives are especially for the reduction of associated anxiety.

55/55 (100%)

54/55 (98%)

# 21 – Document all pharmalogical interventions on a systematic pain record.

55/56 (98%)

37/55 (67%)

*While 66 individuals participated in the focus groups we only received responses 58. In summary, the focus group members recommended the following changes to the guideline adaptation: # 1 – Screen and assess once a day for pain. Reassess after each procedure.

• Provide example of what constitutes a procedure. • Include monitoring for pain ‘before’ procedures as well as ‘after’ procedures. • Change the terminology from “once a day” to “at least once per shift.”


# 2 – Assess using standardized tools • Consider different standardized tools in acute care versus rehabilitation contexts.

# 3 – Parameters of assessment should include…Validate the assessment with others.

• Develop a flow sheet to tick parameters related to pain. # 6 – Teach patient and family to document pain assessment.

• Include standardized questions for families to assist with pain assessment. # 10 – Ensure individualized selection of analgesics, considering the intensity and type of pain.

• Include the physician as part of the pain management team. # 11 – Advocate for use of simplest analgesic and least invasive modalities.

• Simplest could mean the simplest form of effective medication.

# 15 – Ensure individuals understand the importance of immediately reporting unrelieved pain. • Include an extensive education of patient regarding what would be an expected ‘normal’ course of pain. • Engage patients in pain monitoring.


• Include an extensive education program regarding opioid management and assessment for the health care team.

Recommendations for Next Steps: 1. GTA Rehab Network to disseminate the summary of survey findings to all Network members with copies of

the guidelines and adaptation for use in each organization. Also disseminate the findings of this study through conference, publication and workshop opportunities.

2. Profile the findings of this project and the associated guidelines amongst educations to support a necessary

cultural shift in clinical practice. 3. Provide the results of this study to the Bone and Joint Health Network – Hip Fracture Rapid Assessment and

Treatment Program which is unfolding across Ontario with a view to facilitating incorporation of the best practice guidelines for pain into the hip fracture clinical practice guideline. Suggest creation of a pain management best practices task group that would focus on finding opportunities and developing tools to support implementation of the guidelines in hip fracture settings.

Conclusions: As a result of this study, we have demonstrated that the RNAO Best Practice Guideline for Pain is applicable to the hip fracture population. We have also produced the following deliverables

• Translation of the guidelines into a video and slide show as well as a 21 point adaptation that offers the guideline in an accessible, evidence-based format.

• Development of empirically relevant hip fracture cases that can be used for teaching purposes to facilitate understanding of current pain management practices.

• Adaptation developed with a multidisciplinary team that can be used to disseminate information and facilitate uptake of the guidelines with hip fracture patients.


• Evaluation of the extent to which clinicians believe the adaptation represent best practice. • Evaluation of the extent to which clinicians believe that the adaptation presents feasible practice and what

needs to be improved. • Demonstration of the use and application of a novel facilitation approach called Build-a-Case which

clinicians can apply in their own training initiatives. The project is an example of how multiple organizations, disciplines, education, practice networks, researchers, clinicians can work together to move research into practice. We hope that the findings of this study will encourage clinicians and organizations to implement the guidelines in order to improve pain management practices for hip fracture patients.


EXPLORING THE APPLICABILITY OF THE RNAO BEST PRACTICE GUIDELINES

FOR PAIN ASSESSMENT AND MANAGEMENT

Ryan, D., Saryeddine, T., Watt-Watson, J., Crilly, R., Moir. J, Levy, C., Gibson, M., McMullan, J., Kontos, P., Korkola, L., Gagliese, L., with Research Associates Leslie Soever and Crystal MacKay

Funded by the Canadian Nurses Foundation – (Nursing Care Partnership program made possible

by a grant from the Canadian Health Services Research Foundation) Acknowledgements: The GTA Rehab Network graciously acknowledges the investigative team (Appendix B), the funders and focus group participants. Special thanks to Leslie Soever, Crystal McKay, Janet McMullan, Ellen MacKenzie, Sylvia Davidson, Ken Wong and Linda Milan for their work on this study. Thanks also to the Fractured Hip Rapid Assessment Treatment program for facilitating the first set of focus groups. 1.0 INTRODUCTION The purpose of this project was to explore the applicability of the Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline for Pain Assessment and Management to the hip fracture population transitioning over the last 24 hours of acute care to the first 24 hours of inpatient rehabilitation. The specific objectives of the research addressed in this report are:

• To identify themes related to current pain management practices. • To compare and contrast qualitative and quantitative findings with respect to the best practice guidelines

for pain management • To highlight content related to applicability and/or feasibility of each best practice guideline.

The research undertaken was a qualitative case study in which the case was both the object of study and the methodology. This study also contributes to our growing understanding and the body of research aimed at increasing the rates of pain assessment and management in the elderly hip fracture patient by systematically exploring the extent to which existing pain research can be applied to this population, identifying knowledge transfer interventions, and identifying and addressing contextual barriers to implementing best practices for this population group. The following report summarizes the methodology assumed, the results of the investigation and makes recommendations aimed at enhancing uptake of the best practice guidelines. 2.0 BACKGROUND Hip fractures are the second leading cause of hospitalization among elderly patients (Beaupre, 2005). The annual economic implications of hip fracture in Canada are estimated to increase to 2.4 billion dollars by 2041 with a current cost per patient averaging close to $27,000 (Lewis et al, 2005). In the Greater Toronto Area and London together, there are over 3,500 patients with hip fracture each year (GTA Rehab Network, 2006; Jaglal et al, 2001). More than 30% are over the age of 85 and of these patients, dementia is estimated to occur in 25-50% (Fleming, 1995). Pain, injury, disability and recovery have been identified as the four thematic experiences of individuals with hip fracture (Archibald, 2003). In spite of this, pain is significantly under-assessed and poorly treated in this


group of patients. The reasons for which have been studied at length. Many of the barriers impacting providers are related to misperceptions about the elderly, opioids, addiction, adverse events and the ability to assess pain in patients who are unable to communicate. Past research has demonstrated and documented that pain is under-assessed and poorly treated in elderly hip fracture patients with those with dementia at greatest risk of under treatment (Forster et al, 2000; Brummel-Smith, 2002; Egbert, 1996; Ardery et al, 2003; McDonald and Hilton, 2001; Adunsky et al, 2002; Forester et al, 2000; Herr 2004). Failure to properly assess pain results in poor pain management because of the inability to determine an appropriate management plan (Feldt and Gunderson, 2002; Murdoch et al, 2004). Unrelieved pain may lead to a poor quality of life for the patient, a violation of the ethic of beneficence (Miller et al, 2000), compromised functional outcome and serious physical conditions brought on by the physiological responses to pain that are poorly tolerated by the older adult (Morrison and Siu; 2000; Feldt and Oh, 2004; Felt et al, 1998; Egbert, 1996). Past research has also documented that transfer with out adequate pain management and related documentation creates one of the vulnerabilities for patients being transferred across settings and precludes effective discharge (Coleman et al, 2005; Naylor, 2000). The intensity of pain is often undocumented which prevents adequate analgesic administration as the patient transitions to the next clinical practice setting (Tittler et al, 2003). Since verbal reporting is often the most reliable indicator of the person’s pain experience (Bergh et al, 1997), poor documentation is especially problematic for a patient with hip fracture and dementia or cognitive impairments because of the potential inability to clearly articulate the pain experience to multiple providers (Egbert, 1996). Transitional care is especially important for hip fracture patients since approximately 30% of hip fracture patients are transferred from acute care to an inpatient rehabilitation bed (GTA Rehab Network, 2006). In all the articles reviewed, only one article was found that dealt explicitly with the transition management issue from acute care to the next phase of care (Feldt and Gunderson, 2002). In this study the authors measured the amount of analgesia being given the last 24 hours of hospital stay and the first 24 hours of stay in the nursing home or rehabilitation facility. They found insufficient continuity of pain treatment and communication. It is these 48 hours spanning the transition between acute care and home care services that are the focus of this study of the application of the RNAO pain best practice guidelines (BPG). Several articles focus on the reasons for which this problem occurs and it is the nature of these barriers to effective practice that provides the context for this research. First, there is a dearth of best practice information for pain management as it applies to hip fracture patients. Feldt and Gunderston (2002), quote a study by Anders and Ornellas in which 52 articles on management of hip fracture patients were reviewed. None of the articles had any discussion of pain management. Second, while barriers to practice arise at the patient, provider, organization and system levels (Jacox et al, 2004 in Chopra and Smith and Briggs, 2004), the barriers related to provider practice are largely associated with misperceptions, a lack of education on pain management practices and false information. For example, Auret and Schug (2005) found that poor assessment practices due to a lack of familiarity with an acceptable tool; fear of polypharmacy and avoidance of opiods due to concerns about tolerances, physical dependence, addiction and adverse events precluded providers from effective pain management practices. Jacox et al, 1994 in Chopra and Smith and Briggs, 2004 each propose a model in which the elderly patient, the provider and the healthcare system present a series of factors that impeded effective pain management. Factors related to the provider include misperceptions about: the extent to which an elder patient experiences pain and the effects of aging on pain perception. In addition, a lack of education on effectively assessing pain, a lack of training in the use of various prescriptions, fear of opiods and concern about addictions also posed barriers to providers. These factors are also supported in a study by Smith (2005). From this literature, it can be seen that addressing provider barriers to improved pain management practices is closely related to correcting misperceptions and providing information and education through techniques such as problem based learning (Ryan, 2004). In problem based learning,


learners are provided with clinical relevant scenarios, access to evidence, maximized opportunities for self directed learning and small groups through which to reflect and discuss (Ryan, 2004). 3.0 RESEARCH QUESTION AND PROPOSITION The impetus for this research was based on evidence that provider-related barriers to effective pain management practices for hip fracture patients are related to misperceptions and poor information. Since the RNAO BPG for the assessment and treatment of pain recommendations 1-66 provide content for education on these issues, we hypothesized that by enabling use of the knowledge from the guidelines in practice scenarios, we will be able to influence a practice change for providers. The research question was therefore stated as follows: “What is the applicability of the best practice guidelines to the hip fracture population transition from the last 24 hours of acute care to the first 24 hours of inpatient rehabilitation from the perspectives of individuals involved in the direct provision of care?” 4.0 RESEARCH METHODS The research was based on a case study design. Case study design is a preferred strategy when trying to explain complex social phenomena such as individual and organizational processes (Creswell, 1995). The strength of this methodology is that it investigates a phenomenon within its real life context and addresses situations in which the boundaries between the phenomenon and the context are not clearly evident (Creswell, 1995). In the proposed research, context and phenomena are complicated by the potential heterogeneity of patients, organizational treatment practices and the fact that the phenomenon of interest is the transition between to two settings. It is also complicated by the nature of pain as a subjective and multi-faceted experience (Creswell, 1995). Overview

Using a unique facilitation methodology called Build-a-Case (Ryan, 2004), eight focus groups with a total of 66 professionals from acute care and inpatient rehabilitation professionals caring for hip fracture patients developed patient cases that reflected their actual practice. The focus groups were then asked to discuss pain management, specifically as it relates to this population. Emerging themes were recorded and analyzed according to accepted qualitative methods. The focus groups were then provided with either a video or face-to-face person presentation of the best practice guidelines, PowerPoint slides and a checklist reflecting the 21 points adapted from the guideline. The guideline adaptation process recommended by Ferver (2006) was used to ensure that the lengthy guideline could be processed and used during the session. After the presentations, the participants were asked to reflect on the specific patent case and to complete a questionnaire which contained the 21 points of the guideline adaptation. The participants were asked to indicate the extent to which they believed the point was best practice and the extent to which they believed it was feasible in the practice setting. The sheets were collected and the transcripts analyzed. The research team consisted of psychologists, rehabilitation professionals, physicians, nurses and gerontologists. One member of the research team (JW) was on the authorship team of the pain assessment and treatment guidelines. Two skilled research associates were also retained to ensure consistency and objectivity in the analysis of the transcripts. Adaptation of the RNAO Best Practice Guidelines

A critical part of the methodology for this study was the development of an adaptation of the guidelines that would enable the focus groups to understand and process the implications of the guidelines in a reasonable amount of time. The adaptation of guidelines has become very common practice in the field of knowledge translation. Since 2000, several articles have addressed this issue and at least one review of the literature and conceptual framework/procedure has been outlined in an international peer reviewed journal (Fervers et al, 2006).


This paper, authored by Ferver et al (2006), provides a review of 18 studies on guideline adaptation. The paper concludes that the adaptation of guidelines is a common and necessary step in the implementation phase. Since there was no commonly accepted process for the adaptation of guidelines, Ferver and colleagues (2006) used the review of the literature to propose a stepwise approach to guideline adaptation consisting of the following steps:

1. Define the clinical questions that will be included in the final guideline, i.e. what are the practice issues that motivated the potential use of a guideline?

2. Search for source guidelines (in this case the RNAO BPG is the source guideline). 3. Assess the clinical content of the guideline by comparing questions covered by the guidelines with the

clinical question of interest as defined in step one. 4. Evaluate the quality and coherence of the source guidelines using the AGREE tool and evaluate for each

question the currency of the literature, the coherence between research and evidence and the applicability and acceptability of the recommendations to the context of use.

5. Adaptation of the recommendations. 6. External review of adapted guidelines. 7. Adoption, endorsement and implementation of the adapted guideline.

In adopting this approach, the research team felt confident that as long as the “recommendation” did not change, changing the guideline would not introduce methodological issues in keeping with the research tradition in this area (Ferver et al, 2006). To ensure the reliability of the process, the synopsis was developed by 3 members of the co-investigative team with the appropriate expertise in clinical practice, research and guideline adaptation. At least one of the three co-investigators was an author of the original guideline (Dr. Judy Watt-Watson) and at least one of the co-investigators is responsible for the implementation of guidelines at a large teaching hospital in Ontario (Dr. Richard Crilly). The co-investigators involved in the guideline adaptation, provided a systematic accounting of where and how each of the recommendations in the original guideline became reflected in the adaptation. It should be noted that only recommendations 1-66 are included in the adaptation, since the following recommendations # 66 are geared at how organizations and the system may support implementation of earlier recommendations. The rest of the co-investigative team provided an objective assessment of how the adaptation compared both to the original guidelines and to the Ferver et al process of adaptation. The workshops were used to discuss the applicability of the recommendations in the guideline to the hip fracture population were monitored and formally evaluated after the first set of workshops and were modified to accommodate any problems in the process. Knowledge to Practice Workshops

The research team conducted three separate workshops with health care providers (including allied health professionals and nurses) who worked in acute care or inpatient rehabilitation settings. A total of 66 participants were involved in focus groups across three dates and were given the opportunity to participate in one of eight small, facilitated discussions to reflect on the patient profile and current practice in relation to assessment and management of pain. The participants were recruited through email invitations sent by the GTA Rehab Network and the Fractured Hip Rapid Assessment and Treatment program, both of which have access to the providers of hip fracture care in publicly funded hospitals in the Greater Toronto Area and across Ontario. Individuals self selected into the study and were eligible if they were directly involved in the provision of care to hip fracture patients in either acute care or inpatient rehabilitation settings and had either an allied health or nursing background. The focus groups were then organized so that the participants reflected the mix of settings and professions. For feasibility reasons, multiple focus groups were conducted in different rooms at the same time so that the different focus group participants could reconvene for the educational in sessions that would be common to all groups. We discuss how we prevented confounders later in this section.


At each focus group the facilitator, using the interview guide in Appendix C, asked the participants to think about the typical hip fracture case and discuss the most important treatment elements. This part of the discussion is the foundation for the Build-a-Case methodology which is described below. Build-a-Case (BaC) is an approach to problem-based learning that was developed by one of the Principal Investigators (Ryan, 2004). It has been used for training in dementia care, congestive heart failure, end of life care, elder abuse, geriatric emergency nursing and care of the homeless senior. It is also curriculum element in the national Ian Anderson Foundation Continuing Education Program in End-of-Life Care and has been used as a service planning and needs identification tool for the Ontario Dementia Networks.

In step one of BaC, clinicians are asked to describe or ‘build’ the profile of a typical patient, in this case a hip fracture patient in the last 24 hours of acute care and the first 24 hours of rehabilitation. This becomes the empirical example that is used in the second step of determining how to assess and treat the patients’ pain. The advantage of having the clinicians build this empirical example is that it bears relevance to their experience, contextual nuances and practice realities. The facilitator’s role is to record the discussion of the client’s characteristics on flipcharts until a full patient profile emerges. The facilitator helps the group refine the profile of the client, by including the characteristics common to the group’s experiences and “parks” those characteristics that are insufficiently relevant to the collective group experience of these patients. (Facilitator Guidelines are included in Appendix C).

Once the profile has emerged, the facilitator then closes the case and asks the group how pain will be assessed and managed for that patient. The facilitator records the diversity of treatment options, opinions and preferences generated in the discussion. In the next phase of the workshop, a presentation is made to the group on the RNAO BPG for pain assessment and management, focusing specifically on recommendations 1-66 and more specifically on the recommendations regarding documentation, assessment, opioids, contra-indications and addictions for which the level of evidence is A or B. Dr. Judy Watt-Watson, one of the authors of the RNAO BPG and the Adapted Guideline, generated these workshops to ensure the information was introduced in a consistent and user-friendly manner. The group was told that the guideline recommendations were not all level A or B evidence and that they were general and not developed in consideration of any specific group of patients. This allowed the group the opportunity of reflection without being constrained by any appeal to the authority of the guidelines. The fourth part of the workshop involved a discussion of how the guidelines resolve some of the diversity of opinions, support the practice decisions previously proposed, or were not applicable to the situation or context. In the final stage, the participants reflected on the fundamental applicability and feasibility of the guidelines and made recommendations for change that would support enhanced adoption of the guidelines. It should be noted that for this part of the discussion, we asked individuals participating in different focus groups (i.e. building different patient cases) to come together for a group discussion. The individuals were asked to record their individual perspectives by patient case on individual worksheets which were collected. This enabled a comparison of the responses by patient and in general and a comparison of descriptive statistics to qualitative analysis themes.


Qualitative/Quantitative Data Analysis

Electronic verbatim transcripts were professionally prepared for each focus group discussion and analyzed using thematic analysis techniques (Denzin and Lincoln 1998). The 11 transcripts (eight of which were Build-a-Case and three of which were focused on the group discussions regarding the RNAO guidelines) were independently analyzed by two consultants (Soever and MacKay) to identify emerging themes related to:

• description of each case (typical patient with hip fracture in the last 24 hours of acute care and the first 24 hours of inpatient rehabilitation);

• pain management; and • assessment of 21 best practice guidelines.

The data were entered into N6, a qualitative software package that was used to facilitate the organization of the data. Descriptive coding was first conducted wherein segments of text were assigned a code reflecting the original statement. Codes that addressed a similar topic were then grouped into categories. Emerging codes with resultant categories were identified independently by the two consultants and agreement on these codes and categories was reached through discussion by both. Upon completion of this analysis, results were compared with flip chart summaries of Build-a-Case scenarios and questionnaires related to each case for best practice guideline adaptation. Descriptive statistics were used to summarize data from the questionnaires. 5.0 RESULTS Transcripts were prepared and analyzed for the eight ‘Build-a-Case’ group discussions and the three post-education large group discussions about the RNAO Best Practice Guidelines. From this analysis, five main categories of information emerged across all sessions including:

• description of a typical patient with hip fracture; • acute care and inpatient rehabilitation processes; • pain management; • facilitators and barriers to pain management; and • suggestions/concerns re RNAO Best Practice Guidelines.

Four additional themes emerged in the second and third session that had previously not been raised. These were: • emergency room process; • inpatient rehab process; • barriers to pain management/care; and • medication side effects.

Of the initial emergent themes from the first phase, the following themes did not emerge in this second and third phase of focus groups:

• communication - Internal/External; • details of pain; • duration of pain; • facilitators to pain management – clinical champion; • facilitators to pain management – senior management buy-in; and • pain prevention.


Table 1: Emergent themes

Description of a typical patient with hip fracture

Acute care and inpatient rehabilitation processes

Pain management Facilitators and barriers to pain management

• Hip fracture characteristics

• Cognition • Living situation • Effect of language barrier

on pain • Post-operative delirium • Comorbidities • Family involvement

• Length of stay • Goal-setting • Rehabilitation criteria • ER process* • Acute care process • Inpatient rehab process* • Team • Communication • Communication –

internal/external** • Factors affecting

discharge destination • Process for transfer to

rehabilitation

• Pain symptoms • Physical effects of pain • Duration of pain** • Details of pain** • Pain management • Pain measurement • Pain measurement –

trends • Transition from IV to

oral medications • Dosage • Protocol • Perceptions of pain –

healthcare provider • Pain prevention** • Patient education

regarding pain • Frequency of pain

monitoring • Suggestions re

guidelines* • Concerns re

guidelines*

• Barriers – healthcare provider

• Barriers – lack of time • Barriers –

understanding culture • Barriers – access to

specialists • Barriers – transfer

issues • Barriers – lack of

education • Barriers – bowel side

effects • Barriers – medication

side effects* • Facilitators – senior

management buy-in** • Facilitators – clinical

champion** • Facilitators – family

involvement • Facilitators – access to

specialists *Additional emergent themes **Non-emergent themes for second phase of focus groups While there were a number of themes related to the first two main categories (description of a typical patient with hip fracture; and acute care and inpatient rehabilitation processes), these will not be the focus of this report. Rather, after a brief description of the typical hip fracture patient, this report will focus on the participants perceived current pain management practices and the applicability and/or feasibility of each best practice guideline. Most of the data related to these objectives can be found in themes from the third and fourth categories of information. Description of the Typical Hip Fracture Patient

In four out of five Build-a-Case scenarios, the typical hip fracture patient was a woman. The average age was 82.8 years, ranging from 79 to 90 years of age. The typical patients had co-morbidities (e.g. visual difficulties, diabetes, hypertension) and cognitive difficulties or delirium reported during their hospital stay. All patients in the scenarios lived alone. Most patients had families; however, they did not always live close by and/or were not providing daily support. Current Pain Management Practices

As was mentioned, participants worked in one of two clinical settings: acute care or inpatient rehabilitation. In some instances the inpatient rehabilitation units were located within the same physical hospital, while in others the inpatient rehabilitation unit was located in a separate site from the acute care hospital. It is apparent that there


is variability in current pain assessment and management practices across clinical settings and institutions. Following are examples, illustrating common practices with respect to various aspects of pain assessment and management. a) Pain Assessment Data on pain assessment are largely found in emergent themes: pain measurement and pain measurement – trends. Clinicians reported assessing patients for symptoms of pain in a variety of ways, including use of standardized measures such as numerical rating scales, observation of behaviours and communication with family. The following quote illustrates use of standardized measures:

“I know when we do our assessment, there’s a section on our assessment form for pain and we’ll usually get them to rate their pain on a numeric scale. So from zero to ten, how much pain are you having? We will do it at rest and with activity. Does it increase? We are looking for pain history, basically, what brings it on, what takes it away, that type of thing.”

Observation of behaviours as a form of assessing pain, particularly for patients with cognitive and/or language barrier issues is illustrated by the following dialogue:

“Facilitator: What would you look for? Participant: Facial expression… willingness to move… reaction to touch… abnormal posture.”

Communication with the family was a less frequently used approach for assessment of pain but was also discussed in the context of cognitive and language barrier issues. b) Pain Management Themes regarding pain management are illustrated by the following: pain management; transition from IV to oral medications; dosage; protocol; patient education regarding pain; and frequency of pain monitoring. Throughout the Build-a-Case discussions, participants reported a number of pain management practices which included care pathways/protocols with a logarithm for pain management, as well as less standardized routine practices. Details of the pathways/protocols and practices varied with respect to types of medication, route of medication (oral, intravenous, spinal) and frequency of monitoring and dosing as illustrated by the following quote and dialogue, respectively:

“So no protocol at this point. It really is physician driven, physician preference. The nurses and the physios and the OTs (the team) work with the patient and they really do give that feedback to the physician, pharmacist, whoever who is doing the dosing, about whether or not the patient is progressing but because of the pain…you need to reassess their medications.” “Facilitator: We have oxycontin, or we have Tylenol, or maybe something else… Participant 1: I would say Tylenol. Facilitator: Standing Tylenol? Participant 1: Yes. …. Facilitator: Standing Tylenol – any dosages? Participant 1: Every four hours. Participant 2: Every four hours. Participant 3: Our surgical unit never forgets that, so a PRN… Participant 4: We are not that good at having a standing … standing is me saying to the nurse every day make sure you give her pain pills at breakfast… that’s right and that’s the problem it doesn’t come as a standing order, it usually comes as a PRN order.. they give us a lot of choices, but it’s […] seldom a standing order”


Participants also identified patient education as a component of pain management; in particular, education regarding expectations of pain as well as pain management practices was discussed. The following quote illustrates patient education practices:

“I heard someone just the other day tell a patient the first day after surgery … it’s not like that’s going to fall apart, yes it hurts… but it will hold you up.”

c) Specialized Pain Management Teams/Clinicians Themes related to pain management teams/clinicians are illustrated by the following: pain management, team and facilitators – access to specialists. Participants identified a number of different types of health care providers that acted as pain specialists individually or as part of a pain team in their institution including anaesthetists, geriatricians, clinical nurse specialists, specialized pain teams and pharmacists. Access to any type of specialists in pain management varied across settings and institutions. Some participants identified that access to such specialists was a barrier to pain management at some institutions. Examples of access/lack of access to a specialized team are illustrated as follows:

“And with ours, with our fractured hips, they are automatically referred, it is an automatic referral to the geriatric team, so the minute they are in bed post-op, they are covered by our geriatric team.” “I think most of us do agree that we should have some sort of routine management process… but it’s having the resources to get that, you know in our facilities it is almost impossible, it takes a lot of money to implement something like this and we all have a little bit of knowledge about pain. I do think we need some sort of pain management team but it is difficult to get because of the limited resources.”

d) Communication Themes regarding communication about pain management are illustrated by the following: pain management, team and communication. Communication, on two main levels, including amongst staff on individual units (acute care and rehabilitation) and between acute care and inpatient rehabilitation especially during transfer, was discussed as part of routine practice. This communication takes the form of both, verbal dialogue amongst clinicians, as well as written documentation:

“Participant 1: do therapy sessions after she has had pain medication. Facilitator: coordinate therapy sessions. Participant 1: coordinate with nursing… and see when they are giving pain meds.” “Right… there will have been a report though between the nursing staff from acute to rehab and usually that is discussed, like usually it is so, they’ll say, you know she is not due for another hour for her medications so they know when she does come, she gives her something within an hour of coming, something like that.”


How Common was it for Participants to Raise the Topic of Pain? With respect to current pain management practices for patients with hip fracture, the consultants tabulated the frequency that the participants of the second and third focus groups initiated the topic of pain assessment/ management versus the frequency that the facilitator initiated the topic of pain assessment/management. The topic of pain was raised more frequently by the facilitator (n=17) compared to the participants (n=10). Table 2: Frequency of introduction of topic of pain assessment/management (second and third sessions only)

Case/Patient * this analysis was undertaken in sessions 2 and 3 only so data does not exist for 3/8 cases built.

# of times facilitator raised pain topic

# of times participants raised pain topic

Initial mention of pain (F=facilitator) (P=participant)

Gladys 1 2 F George 5 1 P Millie 6 2 P Jean 1 2 F Mrs. Jones-Sanchez 4 3 P Total 17 10 Applicability and Feasibility of RNAO Best Practice Guidelines

The focus groups provided additional data regarding the applicability and feasibility of the RNAO best practice guidelines for pain management. Table 3 incorporates both the findings from the questionnaires and focus groups. The quantitative findings from the questionnaires are reported in column two. Content related to applicability and/or feasibility, including concerns and suggestions of each best practice guideline, is highlighted in columns three and four of Table 3. Response rates for each question in the questionnaire varied. Overall, most participants agreed with the majority of the guidelines. The number of participants who indicated they agreed with the guideline ranged from 93% for guideline #6 to 100% for most of the other guidelines. There was more variability in the responses to the feasibility of the guidelines with only 61% of respondents agreeing to guideline #6, 67% agreeing to guideline #21 and 68.0% agreeing to guideline #3. For guidelines #3 and #21, there were no qualitative data to illustrate participants’ concerns regarding feasibility. Agreement with all other guidelines was greater than 75%. From the qualitative data, participants reported concerns with some of the guidelines as they were written and provided suggestions for improvement (Table 3). In some instances where the quantitative data suggests lack of feasibility (e.g. guideline # 21), there were no specific data from the transcripts to illustrate the concerns. In addition to the concerns reported related to the specific guidelines in Table 3, a more general concern regarding time availability was raised, particularly in reference to burden on nurses, as illustrated by the following:

“I don’t think there’s anything that won’t work… it’s just that the time involved in doing it makes it a little bit of a barrier especially for the nursing staff. I think therapists do it a bit but I think if you’re a nurse who’s doing this every shift, I think the time involved in being really thorough might be an issue.”


It was also suggested that education for the team regarding the guidelines was important for success as illustrated by this quote:

“I think it’s more the feasibility at the organization that if we’re going to commit to implementing it, we have to commit to educating the staff on… the components of the guidelines.”

Table 3: Summary of findings from the descriptive statistics and transcript analysis for each point in the guideline adaptation

Guideline (point in the adaptation) Agree with

point in adaptation N* (%)



# 1 – Screen and assess once a day for pain. Reassess after each procedure.

56/58 (97%)

54/58 (95%)

Lack of specificity in the guideline regarding what constitutes or defines a procedure. Frequency of reassessment, for example, is once/day adequate.

Provide example of what constitutes a procedure. Include monitoring for pain ‘before’ procedures as well as ‘after’ procedures. Change the terminology from “once a day” to “at least once per shift.”

# 2 – Assess using standardized tools.

58/58 (100%)

51/58 (89%)

Balance between use of standardized tools for formal assessment and informal assessment.

Consider different standardized tools in acute care versus rehab.

# 3 – Parameters of assessment should include the following parameters: location; intensity; medication; precipitating factors; quality of pain; radiation of pain; timing; impact of pain; preferences about management, situational, coping responses, meaning of experience, understanding of disease, psychosocial and spiritual effects; record of interventions; impact of interventions. Validate the assessment with others.

56/57 (98%)

38/56 (68%)

Develop a flow sheet to tick parameters related to pain.

# 4 – Unexpected pain should be immediately evaluated.

58/58 (100%)

56/57 (98%)

# 5 – Document and make documentation available to other clinicians.

56/57 (98%)

50/56 (89%)





# 6 – Teach patient and family to document pain assessment.

51/55 (93%)

34/56 (61%)

By having patients and/or family record pain logs, there is a potential to inadvertently increase the focus on pain. Some patients may not have the family support to assist with recording on pain logs.

Include standardized questions for families to assist with pain assessment.

# 7 – Advocate for changes in treatment plan if pain untreated.

58/58 (100%)

50/56 (89%)

# 8 – Refer patients with chronic pain to a specialist.

57/57 (100%)

43/56 (77%)

Feasibility of dealing with chronic pain due to lack of resources.

# 9 – Establish a pain management plan that includes, at a minimum, the assessment findings, baseline characteristics, physical and psycho-social characteristics, etiology, pharmacological and non-pharmacological strategies, management interventions, current and future primary care treatment plans.

55/57 (96%)

44/56 (79%)

# 10 – Ensure individualized selection of analgesics considering the intensity and type of pain.

58/58 (100%)

54/57 (95%)

Use of word ‘ensure’.

Include the physician as part of the pain management team.

# 11 – Advocate for use of simplest analgesic and least invasive modalities.

57/57 (100%)

54/56 (96%)

Fear of under medication

Simplest could mean the simplest form of effective medication.

# 12 – Do not use merperidine for the treatment of chronic pain unless for a very brief acute pain situation and do not use it for patients with impaired renal function

48/49 (98%)

44/48 (92%)

# 13 – Administer analgesics on a regular basis.

56/56 (100%)

50/54 (93%)





# 14 – Evaluate efficacy of pain relieve at regular intervals.

57/57 (100%)

52/54 (96%)

# 15 – Ensure individuals understand the importance of immediately reporting unrelieved pain.

57/57 (100%)

50/54 (93%)

Include education of patient regarding what would be an expected ‘normal’ course of pain. Engage patients in pain monitoring.

# 16 – Use an equi-analgesic table to ensure equivalency.

49/49 (100%)

36/45 (80%)

# 17 – Advocate for consultation with a pain management expert for complex pain situations.

56/56 (100%)

44/53 (83%)

What constitutes a pain management team.


56/56 (100%)

52/56 (93%)

Include an extensive education program regarding opioid management and assessment for the health care team.

# 19 – Recognize the difference between drug addiction, tolerance and dependency.

57/57(100%)

47/54 (87%)

# 20 – Anticipate pain that may occur during treatments. Recognize that anxiolytics and sedatives are especially for the reduction of associated anxiety.

55/55 (100%)

54/55 (98%)

# 21 – Document all pharmalogical interventions on a systematic pain record.

55/56 (98%)

37/55 (67%)

*While 66 individuals participated in the focus groups we only received responses 58.


6.0 DISCUSSION We have used a unique qualitative approach and educational intervention, Build-a-Case, to demonstrate that the RNAO best practice guidelines for pain assessment and management are applicable to hip fracture patients transitioning from the last 24 hours of acute care to the first 24 hours of inpatient rehabilitation. In addition, we have developed a series of important deliverables that can be used by all health system stakeholders to improve the assessment and treatment of pain in hip fracture patients. What do the results of this study provide to the Canadian Nurses Foundation, to the GTA Rehab Network, to the Regional Geriatric Program, providers of rehabilitation and acute care and ultimately to the patients at the centre of this study? The results are important in that they document that the RNAO guidelines provide a vehicle to improve the way we treat pain in patients with a hip fracture, through their adaptation and implementation, to make changes in the current practice setting. These results provide tools that help to translate the guidelines to fit a specific practice setting and that can be used in the educational curricula of incoming clinicians. The classical clinical decision making model, i.e. how clinicians make practice decisions, integrates consideration of the evidence with preferences and realities of the practice setting (Haynes et al, 2002). Since the RNAO Guidelines for pain assessment and management are based on a review of the literature and discussion with experts, it already serves as a much needed repository and synthesis of information. In fact, the absence of syntheses of the literature is one of the limiting factors in allowing clinicians to use evidence in practice. By further translating the evidence in the guideline into an adaptation, we have increased its usability and accessibility. This is consistent with recommendations made in the literature (Ferver, 2003). Then, clinician input about whether each point in the adaptation reflects best practice provides insight into their beliefs, attitudes and preferences about pain management in the context of caring for hip fracture patients in transition periods of care from one. Finally, by asking about the feasibility, we have gained the opportunity to understand the realities of the practice setting. In general, the qualitative analysis, as well as the descriptive statistics that we collected (it is important to note that we do not have sufficiently large sample size to permit quantitative reporting on the guidelines), show that while all recommendations were considered best practice and feasible, there were a few areas of concerns. The most important concerns were related to the recommendations to involve the patient and/or family in keeping a record, log or diary of pain experiences. Participants were concerned that drawing the patients’ attention to pain would result in them being too aware of the pain and therefore not being willing to engage in rehabilitation activities which by their nature may be painful. There has been considerable expansion of this research in this area in recent years that has contributed to our understanding of the relationship between pain-related fear, avoidance behaviors and ongoing disability. Vlaeyen and Linton (2000) through an extensive review of research studies demonstrated that fearful patients performed less well on behavioural performance tasks. A number of other studies have demonstrated that pain related fear was associated with decreased speed in walking (Al-Obaidi et al, 2003) and with diminished performance on physical tasks (Geisser et al 2000; Vowles and Gross, 2003). “Indeed, a large body of research found that patient with heightened levels of pain-related fear report increased disability” (Leeuw et al 2006). However, fear is not always associated with avoidance behaviour. In some cases, fear may even be associated with persistence rather than avoidance (Leeuw 2006). Pain-related fear can be considered adaptive for an individual, potentially protecting them from further harm. Therefore, further education is required to support clinicians in determining when that fear and anxiety is appropriate and when it may become dysfunctional, impeding participation and recovery. With increased awareness about this interaction health providers will be better equipped to support their patients as they acknowledge the fear but continue to engage in the necessary rehabilitative activity. A second issue of concern was the quality and quantity of pain assessment. There was debate about the feasibility and frequency with which pain assessment should occur. In many cases, clinicians felt that the frequency of


assessment and reassessment had to be increased while in other cases clinicians felt that the reassessment protocol itself was not feasible within the context of current length of stays for this population. In addition, there was a question about whose duty pain assessment and management truly was and what role pain specialists/teams could and should be playing. The issues of interdisciplinary and multidisciplinary care were discussed and the implications of staffing and shift rotations. Specialized interprofessional teams with expertise in pain assessment and management were considered important by many focus group participants. However, opinions varied regarding the composition of the team and issues were expressed regarding leadership, roles and responsibility. Other recommendations that were made on the adaptation include the following: # 1 – Screen and assess once a day for pain. Reassess after each procedure:

• Provide example of what constitutes a procedure. • Include monitoring for pain ‘before’ procedures as well as ‘after’ procedures. • Change the terminology from “once a day” to “at least once per shift.”

# 2 – Assess using standardized tools:

• Consider different standardized tools in acute care versus rehab. # 3 – Parameters of assessment should include…Validate the assessment with others:

• Develop a flow sheet to tick parameters related to pain. # 6 – Teach patient and family to document pain assessment:

• Include standardized questions for families to assist with pain assessment. # 10 – Ensure individualized selection of analgesics, considering the intensity and type of pain:

• Include the physician as part of the pain management team. # 11 – Advocate for use of simplest analgesic and least invasive modalities:

• Simplest could mean the simplest form of effective medication. # 15 – Ensure individuals understand the importance of immediately reporting unrelieved pain:

• Include education of patient regarding what would be an expected ‘normal’ course of pain. • Engage patients in pain monitoring.

# 18 – Anticipate and monitor individuals taking opioids for common adverse effects:

• Include an extensive education program regarding opioid management and assessment for the health care team.

While the formal deliverable for this project was to inform our research question on the applicability of the pain assessment and treatment guideline to this group of hip fracture patients, the research methods yielded a series of other deliverables that are important to the system. These include:

• A guideline adaptation for use by clinicians. A twenty-one point adaptation of the guideline that provides a brief overview of the more than 90 recommendations in the guideline. The adaptation was prepared in keeping with best practices identified in an international review by Ferver et al (2003). In addition, one of the guideline authors provided much of the leadership for the adaptation of the guideline in collaboration with other clinical experts and individuals with expertise in knowledge transfer.


• Video and slide show: Based on the adaptation document described above and with a view to ensure

that this part of the educational intervention was common across focus groups, a web-enabled video and slide show presentation is also available.

• Empirically relevant case studies: As part of the Build-a-Case facilitation methodology that was used

for this study, 8 case studies were developed through the focus groups in which 66 people participated. The case studies reflect empirically relevant practice situations. Since they were built by clinicians in active practice, these case studies can be used for further educational purposes.

• Education and demonstration of a unique approach to knowledge transfer: The Build-a-Case

methodology provides clinicians with the opportunity to explore the application of a guideline to empirically relevant patient cases. The methodology can be applied to the introduction of any guideline to assess the “gap” between current practice and ideal practice. Through our initiative, more than 70 (participants and facilitators) individuals have been exposed to this novel educational intervention.

• Opportunity to influence future hip fracture practice in the GTA: The project team was grateful to

the participation of Janet McMullan, the Project Manager responsible for the Fractured Hip Rapid Assessment and Treatment Program, which is unfolding across Ontario. This provides a direct opportunity to integrate the findings from this study in the development of hip fracture care pathway.

When our research group undertook this opportunity, we did so in the context of the recognition of a very large problem in pain management for hip fracture patients. This project is a contribution to solving the issue by demonstrating that the existing guideline is indeed applicable and for the most part feasible. The limitation of the study however is that further work is needed to change clinical practice. Attention is needed to ensure that the guidelines and the adaptation get out into the field and ultimately impact pain assessment and management practices in health systems. The GTA Rehab Network, with an infrastructure that combines the attention of the senior most clinical and administrative leadership as well as the involvement of front line clinicians is ideally positioned to move this initiative forward. As such, the following recommendations are made: Recommendations for Next Steps:

1. GTA Rehab Network to disseminate the summary of survey findings to all Network members with copies of the guidelines and adaptation for use in each organization. Also disseminate the findings of this study through conference, publication and workshop opportunities.

2. Profile the findings of this project and the associated guidelines amongst educations to support a

necessary cultural shift in clinical practice.

3. Provide the results of this study to the Bone and Joint Health Network – Hip Fracture Rapid Assessment and Treatment Program which is unfolding across Ontario with a view to facilitating incorporation of the best practice guidelines for pain into the hip fracture clinical practice guideline. Suggest creation of a pain management best practices task group that would focus on finding opportunities and developing tools to support implementation of the guidelines in hip fracture settings.


Conclusions: As a result of this study, we have demonstrated that the RNAO Best Practice Guideline for Pain is generally applicable to the hip fracture population transitioning from acute care to inpatient rehabilitation. We have also produced the following deliverables:

• Translation of the guidelines into a video and slide show as well as a 21 point adaptation that offers the guideline in an accessible, evidence-based format.

• Development of empirically relevant hip fracture cases that can be used for teaching purposes to facilitate understanding of current pain management practices.

• Adaptation developed with a multidisciplinary team that can be used to disseminate information and facilitate uptake of the guidelines.

• Evaluation of the extent to which clinicians believe the adaptation present best practice. • Evaluation of the extent to which clinicians believe that the adaptation presents feasible practice and

what needs to be improved. • Use, demonstration and education of a novel facilitation approach called Build-a-Case which clinicians

can apply in their own training initiatives. The project is an example of how multiple organizations, disciplines, education, practice networks, researchers and clinicians can work together to move research into practice. We hope that the findings of this study will encourage clinicians and organizations to implement the guidelines in order to improve pain management practices in hip fracture patients.


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APPENDIX A

RNAO Best Practice Guideline Assessment and Treatment of Pain Adaptation* (Numbers in brackets refer to the statements in the original RNAO BPG)

1. Screen and assess patients once a day for pain and reassess pain after each new procedure. Any unexpected or

severe pain should be immediately evaluated. (#1,5,7)

2. Pain should be assessed using a standardized tools which look for a variety of markers of pain including physiological and behavioural indications. (#1, 2, 4)

3. A pain assessment and reassessment should include the following parameters: location, intensity, medication, precipitating factors, quality of pain, radiation of pain, timing, impact of pain, preferences about management, situational, coping responses, meaning of experience, understanding of disease, psychosocial and spiritual effects, record of interventions; impact of interventions. Validate the assessment with others. (#3, 6, 8)

4. Unexpected pain, especially if sudden or associated with altered vital signs such as hypotension tachycardia or

fever should be immediately evaluated. (#9) 5. Document initial assessment, monitoring tools, reassessment and make documentation available to other

clinicians. (#10, 11, 14) 6. Teach the patient and family to document pain assessment on the appropriate tools. Have the patient and family

use a log or diary and encourage patient/family to report pain to the provider. Provide patients with a copy of the pain management plan. (#12, 16, 20)

7. Advocate to the interdisciplinary team the need to change the treatment plan if pain goes unrelieved. Use

appropriate channels of communication and approach the communication of unrelieved pain as an ethical requirement. (#15, 17)

8. If after the standardized treatments, pain remains unrelieved, refer patients with chronic pain whose pain is not

relieved to a specialist dealing with this type of pain or to a multi-disciplinary team. (#18) 9. Establish a pain management plan that includes at a minimum, the assessment findings, baseline characteristics,

physical and psychosocial characteristics, etiology, pharmacological and non pharmacological strategies, management interventions, current and future primary care treatment plans. (#19)

10. Ensure that the selection of analgesics is individualized to the person considering the intensity and type of pain

(acute, persistent, breakthrough; nociceptive and/or neuropathic) and includes opioids, adjuvants such as tricyclics and anticonvulsants, and/or non-steroidal anti-inflammatory drugs. (#21, 25-28)

11. Advocate for the use of the simplest analgesic dosage schedules and least invasive pain management modalities.

(#22) 12. Do not use merperidine for the treatment of chronic pain unless for a very brief acute pain situation and do not

use it for patients with impaired renal function. (#29) 13. Ensure that analgesic is administered on a regular basis, with appropriate dose, time intervals and titration when

needed. (#30-33, 35)


14. Evaluate the efficacy of pain relief with analgesics at regular intervals and following a change in dose, route or timing of administration. Advocate for changes in analgesics when inadequate pain relief is observed. (#29) Monitor individuals taking analgesics for side effects and toxicity. (#38)

15. Ensure that individuals understand the importance of promptly reporting unrelieved pain, changes in their pain,

new sources or types of pain and adverse effects from analgesics. (#62) Counsel them that adverse effects can be controlled. (#42)

16. Use an equi-analgestic table to ensure equivalency between analgesics when switching analgesic. Recognize that

the safest method when switching from analgesics to another is to reduce the dose of the new analgesic by one-half in a stable pain situation. (#34)

17. Advocate for consultation with a pain management expert for complex pain situations which include, but are not

limited to: pain unresponsive to standard treatment (#24); drowsiness which persists longer than 72 hours post administration (#53); and urgently if there is refractory constipation accompanied by pain or vomiting. (#51)

18. Anticipate and monitor individuals taking opioids for common adverse effects such as nausea and vomiting,

constipation and drowsiness and institute prophylactic treatment and dietary adjustments as appropriate. (#44, 50) Change to a different opioid if nausea and vomiting persist or hallucinations. (#51) Do not use opioids for individuals who are not in pain or in larger doses than necessary as opioids, especially for individuals with respiratory depression, may stop breathing. (#37)

19. Recognize the difference between drug addiction, tolerance and dependency to prevent these from becoming

barriers to optimal pain relief. (#38, 63) Addiction is psychological and is rare with person taking opioids for chronic pain; tolerance can be exhibited and will require upward adjustments of doses, but the dose can remain the same for years; reduction of opioids when no longer needed should happen gradually. (#59)

20. Anticipate pain that may occur during treatments, dressing changes and/or procedures such as medical tests, and

combine pharmacologic and non-pharmacologic options for prevention. (#54, 62-66). Recognize that anxiolytics and sedatives are especially for the reduction of associated anxiety and if used alone blunt behavioural responses without relieving pain. (#55)

21. Document all pharmacological interventions on a systematic pain record that clearly identifies the effect of

analgesic on pain relief and in the home setting can be used by the patient-family. Utilize this record to communicate with interdisciplinary colleagues in the titration of analgesic. The date, time, severity, location and type of pain should all be documented. (#60, 64-66). Also provide patient and family with the pain management plan, any needed documentation and education on when to report pain and complications (# 57, 58, 61)

*Source: Adapted from the RNAO Best Practice Guideline for the Assessment and Treatment of Pain. Full guideline available: http://www.rnao.org/Page.asp?PageID=924&ContentID=720


APPENDIX B RESEARCH TEAM AND COMMUNITY ALLIANCES Dr. David Ryan is a psychologist with 25 years of clinical, research and teaching experience in geriatric medicine and has worked extensively with nurses and in the field of knowledge transfer. He is presently Director of Education for the Regional Geriatric Program of Toronto and an Assistant Professor in the Faculty of Medicine where his specialties are knowledge translation, continuing health professional education and interprofessional practice and was a founding member of the Knowledge Translation Program. He is presently a co-investigator and knowledge to practice expert for several provincial initiatives. He is the author of the “Build-a-Case” methodology which was used in this study. Tina Saryeddine is a PhD student in the management and organizations stream, Faculty of Medicine, University of Toronto. For part of the term of this project Tina was Project Manager and Senior Planner with the GTA Rehab Network. She is now Assistant Director Research and Policy Analysis with the Association of Canadian Academic Healthcare Organizations. Dr. Richard Crilly is a geriatrician and professor at the University of Western Ontario medical school. He provides the intellectual direction for the initiative, the entry mechanism for the London based studies. He specializes in the care of hip fracture patients and osteoporosis. In addition to numerous publications, Dr. Crilly has an extensive network of professionals through the London Hip Fracture interest group which were important in establishing the RPLC. Dr. Lucia Gagliese is a psychologist and CIHR New Investigator. She has extensive research expertise in pain and aging, including the assessment and management of postoperative pain in older people. She is a member of the Expert Consensus Group on Pain in Older Persons and contributed to study design, project implementation, data interpretation and manuscript preparation. Dr. Maggie Gibson is a Psychologist with extensive experience in the development and implementation of clinical practice guidelines for the care of older adults. She is a co-leader for the Canadian Coalition for Seniors Mental Health national best practice guideline series (www.ccsmh.ca), a project funded by the Population Health Fund. She has led and published clinical, quality improvement and research projects on the topic of pain in older adults. She contributed a pragmatic as well as academic focus to the project. Dr Pia Kontos is a medical anthropologist with expertise in person-centred philosophies of dementia care, arts-based approaches to knowledge translation, qualitative research methods, and critical social theory. Dr. Kontos provided methodological expertise and content with respect to the qualitative methods employed in our study and the integration of the qualitative research findings with other data generated. Lori Korkola is a Corporate Practice Leader for Nursing at Toronto Rehab. She has participated in a large number of research, teaching and practice initiatives related to pain and supported the implementation of project and development of focus group methodology. Dr. Judy Watt-Watson is a Professor and Associate Dean, Academic Programs, at the University of Toronto, Faculty of Nursing. She is a Clinical Associate of the Wasser Pain Management Centre at the Mount Sinai Hospital in Toronto, Associate Editor of the Canadian Pain Society’s Journal Pain Research and Management, Chair of the CPS Education Committee, and the Past-Secretary of the Society. Her research has included projects


on pain curricula in Canadian nursing and medical faculties and interventions involving both health professionals and patients to reduce unrelieved pain and improve patients’ quality of life. She chaired the inaugural development and implementation of the UTCSP’s Interfaculty Pain Curriculum. She is Co-chair of the International Association for the Study of Pain Task Force on Multi-professional Education. Dr. Watt-Watson participated in the development of the RNAO pain guideline. Charissa Levy is the Executive Director of the GTA Rehab Network. She is an occupational therapist by training. Judy Moir was Acting Executive Director of the GTA Rehab Network for part of the time this project was underway. The GTA Rehab Network is the primary community alliance partner for this research.


APPENDIX C

FACILITATOR SUMMARY

1. Logistics Part I Facilitate introductions Ask for consent forms; Ask for a time keeper Record the discussion (please write clearly) Suggest facilitators report back since this will be most efficient. 45 minutes max to build the cases [be careful not to get caught up in the details. Time will go

very fast] Ask people to speak one at a time, speak loudly and clearly.

2. Build-a-Case: [45 MINUTES MAX.]

We are going to Build-a-Case of the “typical” hip fracture patient in the last 24 hours of acute care and the first 24 hours of inpatient rehab? We would like you to talk about “actual, not ideal. We recognize that there may be limitations in the reality of the practice setting, so let’s talk about the actual situation rather than the ideal situation”.

What is the name of this post-surgical hip fracture patient? How old is he or she? Does he or she have difficulty with cognition? Does he or she have difficulty speaking? What are the typical issues that need to be addressed?

Allow the conversation to flow as organically as possible. Before delving into prompted questions – make a statement on the recording to signify that you are moving to a more structured part of the discussion. (If any of the points listed below arose in the discussion – check them off and they don’t need to be revisited).

Ask acute care providers: Would this person be in pain? How would you know? How would you

find out? Ask rehab providers: How would you know that this person was in pain if they were? How would

you find out? Can you please describe the pain management plan?

o Would you use analgesics? How would you use them safely o When might you have to switch analgesics and how would you do that safely o When might you use opiods and what issues would you need to consider? o What if any adverse events would you look for?

What (if any role) does the patient have in pain management? Consider specifically the transition: What special things would you need to do?

3. Presentation (approximately 25 minutes)

Logistics for Part II: [MAXIMUM 1 HOUR]

Ask people to record their thoughts on the checklist. You might want to give people a few minutes to

go over the checklist.


Remember, there are 21 points and you have 1 hour so please manage your time. Judy will have already spoken to the guideline and participants may have even completed it during her talk.

1. Think about [Name of Patient] and each of the 21 points in the guideline. Let’s go over the points and

decide which ones we have a disagreement with a) “in principle” and b) “in practice”. 2. Let’s discuss the points that you do not agree with in principle, if any? Don’t worry about feasibility here,

let’s just think about best practice. Which ones are they? Why do you disagree with them?

3. Let’s discuss the points that you feel are unfeasible

Which ones are they? Why are they not feasible? What would make them feasible?

4. Thinking specifically about the transition, are there any points that are not referenced but should be?


APPENDIX D: FINANCIAL DISBURSEMENT REPORT REVENUES Budget Actual Funds received from Canadian Nurses Foundation $29,766 $29,766 In-Kind Contribution from GTA Rehab Network $30,000 $30,000

REVENUES TOTAL $59,766 $59,766

EXPENSES (Related to $29,766.00 from CNF) Budget Actual VarianceResearch/Project Staff $18,716 $12,032.80 $6,683.20Expendables (workshop venues and supplies) $2,700 $2,400.73 $299.27Services (transcription) $3,400 $2,953.99 $446.01Dissemination Costs (development of user friendly material and communications strategy)

$2,100 $0 $2,100

Travel expenses $2,000 $840.39 $1,159.61

Equipment (recorder and software for data analysis) $850 $1,300.34 - $450.34

EXPENDITURES TOTAL $29,766.00 $19,528.25 $10,237.75 Variance Resolution:

• Due to a change in process and increased in-kind contributions from the Research Team, less research assistance/ coordination was required (e.g., the adaptation of the Guidelines was undertaken by the research team, the focus groups were facilitated by the research team members and volunteers).

• Given the timing of the project, the funds allocated for dissemination and knowledge translation has not been spent as we needed to wait until we were clear about the findings of the study. Some of the funds earmarked for travel is associated with the cost of traveling to conference(s) to support the projects knowledge translation mandate. These expenses were not incurred during the span of the project.

Proposed Disbursement of Remaining Funds: REMAINING FUNDS $10,237.75 EXPENSES (Related to $29,766.00 from CNF) BudgetDissemination of Findings through National/International Conferences:

Workshop to support Dissemination among GTA Rehab Member Organizations Catering, Equipment, and Travel Expenses of Presenters

$1500GTA Rehab Network Best Practices Day (March 5 2009, Toronto, Ontario) Canadian Association of Rehabilitation Nurses/Rehab Net Conference (Winnipeg, Manitoba June 3-5, 2008) Canadian Nurses Association’s Nursing Leadership Conference: Leaders in Action: Mobilizing Nursing Leadership (Toronto, Ontario February 8-10, 2009 ) 29th Annual Canadian Pain Society Conference "Pain - Translating Science Into Care" (Quebec City, Quebec May 27-30, 2009) International Association of Gerontology and Geriatrics World Congress(Paris, France July 2009) Travel expenses of presenters and Administrative Support for completion and submission of Abstracts (Note: travel expenses for conferences can be shared as some of the Research Team have other interests in attending certain events)

$4000

Development and dissemination of user-friendly material (i.e., modified guidelines) $4000Writer to adapt report for academic journal submissions $1500EXPENDITURES TOTAL $11,000.00*

*overrun will be covered by GTA Rehab Network


GTA Rehab Network 520 Sutherland Drive

Toronto, ON M4G 3V9

Tel: (416) 597-3057 Fax: (416) 597-7021

[email protected] www.gtarehabnetwork.ca

Exploring the Applicability of the RNAO Best Practice Guidelines for

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