Matching Interventions to Barriers in Pain Management

Ruth CornishProgram Manager

National Institute of Clinical Studies

Role:

To improve health care by helping close important gaps betweenbest available evidence and

current clinical practice

Whatwedo

Whatwe

know

Acknowledgements

• Prof. Sanchia Aranda

• NICS advisors

• Deb Gordon & June Dahl (Wisconsin pain group)

• Pilot hospital teams

Pilot hospitals

Royal Brisbane

Westmead

Newcastle Mater

Peter MacFlinders

Royal Adelaide

Royal Perth

Charles Gairdner

Background

www.nicsl.com.au

Aims1. To improve the identification of patients

with pain

2. To improve the day-to-day management of pain for patients with cancer

3. To integrate effective cancer pain management into the core business of hospitals

Barriers - Institutional

• Lack of institutional commitment

• Poor visibility of the problem

• Professional territorial issues

• Unclear lines of responsibility

• Lack of practical tools & policies

Barriers – Clinicians• Attitudes & beliefs of staff• No routine pain assessment• Under-estimation of patients’ pain• Analgesia misconceptions• Prescribing & administration inconsistencies• Inadequate knowledge and education

Barriers – Patients

• Inevitability of pain

• Stoicism

• Analgesia fears & misconceptions

• Being a “good” patient

• Distracting from treatment

• Trade-offs: analgesics & side effects

Where to start?

Matchinginterventions to barriers

• Lack of knowledge– Educational courses– Evidence based

guidelines– Decision aids

• Beliefs/Attitudes– Peer influence– Opinion leaders

• Lack of motivation– Incentives / sanctions

• Perception-reality mismatch– Audit & feedback– Reminders

• Systems of care– Process redesign

Generic Principle

Institutional

• Lack of institutional commitment– Executive champions

– Peer hospitals?

• Poor visibility of the problem– Audit & feedback to executive

– We have a problem!

Institutional

• Professional territorial issues– get everyone involved– multiple champions

Departments

Pain

Palliative care

Medical/Surgical

Quality/safety

Disciplines

Nursing

Medicine

Pharmacy

Quality/safety

eg.

Clinical

• Inadequate knowledge, education– needs analyses useful

– don’t expect attendance at special meetings

– use existing meetings opportunistically

– include in orientation, rounds, intranet

– nursing competency standards

Clinical

• Attitudes and beliefs–Opinion leaders

–Clinical champions

–Peers

Clinical

• No routine assessment–documented pain scores on vital

sign chart

–reminders

–audit & feedback essential

Clinical

• Prescribing inconsistencies–guidelines and decision aids at

point of prescribing–equi-analgesia cards–standardised prescribing

Patient

• Inevitability of pain; stoicism; being a "good" patient– "your pain is important to us"

– organisation mission statement

– hospital admission/discharge information includes pain management

– ward posters

Patient

• Distracting from treatment–"your pain is important to us"–involve patient in their own pain

management –prompts to discussion

Patient

• Analgesia fears, misconceptions (particularly addiction)–starting morphine is a "threatening

procedure" for cancer patients

–information for patients & families

Matchinginterventions to barriers

Begins with a sound analysis of barriers