PowerPoint Presentation · University of Pennsylvania School of Nursing ... Futuristic Visons Janet...
Transcript of PowerPoint Presentation · University of Pennsylvania School of Nursing ... Futuristic Visons Janet...
3/30/2017
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Military and Veteran Pain Research: A Focus on Measurement Science
and Practice Rosemary C. Polomano, PhD, RN, FAAN
Associate Dean for PracticeProfessor of Pain Practice
Department of Biobehavioral Health SciencesUniversity of Pennsylvania School of Nursing
Professor of Anesthesiology and Critical Care (Secondary) University of Pennsylvania Perelman School of Medicine
Philadelphia, PA
It was 2005 at the 11th International Association for the Study of Pain World Congress, Sydney, Australia.
COL Chester “Trip”
Buckenmaier III, MD
Professor in Anesthesiology
at the Uniformed Services
University of the
Health Sciences
Rollin M. Gallagher, MD, MPH
National Director of Pain
Management, Veterans
Administration and Clinical
Professor Psychiatry/Anesthesiology,
University of Pennsylvania
Daniel B. Carr, MD
Director, Tufts Program on
Pain Research, Education
and Policy
Professor, Public Health and
Community Medicine
Regional Anesthesia in the Battlefield
• In 2003, COL Chester “Trip”
Buckenmaier, MD, inserted
the first regional anesthesia
(RA) catheter for pain control
in a Combat Support Hospital
(CSH) or Field Hospital in
Balad, Iraq
Army Spc. Brian Wilhelm
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Combat Injuries are Devastating
• Most service members with major limb trauma sustained in combat had blast injuries– Improvised explosive devices (IEDs) were most
common
• We submitted a grant to the Department of Defense (DoD)
• In 2007, we received a large DoD grant to investigate multiple pain and behavioral health outcomes with major limb (extremity)trauma
://www.youtube.com/watch?v=crdPbhttpMcqAK4
Regional Anesthesia Military Battlefield Pain Outcomes Study (RAMBPOS) Team
PRINCIPAL INVESTIGATOR (PI)
Rollin M. Gallagher, MD, MPH, Department of Psychiatry and Philadelphia VA Medical Center
CO-INVESTIGATORS, UNIVERSITY OF PENNSYLVANIA
Rosemary C. Polomano, PhD, RN, FAAN, School of Nursing and Department of Anesthesiology
John T. Farrar, MD, PhD, and Wen Guo, PhD, Center for Epidemiology and Biostatistics (CCEB)
David Oslin, MD, Department of Psychiatry and Philadelphia VA Medical Center
SITE PI, DEFENSE AND VETERANS CENTER FOR INTEGRATIVE PAIN MANAGEMENT (DVCIPM)
COL Chester “Trip” Buckenmaier III, MD, Defense and Veterans Center for Integrative Pain
Management (DVCIPM, National Military Medical Center (WRNMMC) in Bethesda, MD
SITE PI, SAN ANTONIO MILITARY MEDICAL CENTER (SAMMC)
LTC Brandon J. Goff, DO, Recruitment at SAMMC in Fort Sam Houston, TX
STATISTICIAN
Lynne Taylor, PhD, Center for Epidemiology and Biostatistics (CCEB)
RESEARCH COORDINATORS
Yolanda S. Williams, MPH, Philadelphia VA Medical Center and University of Pennsylvania
Megan Vaughan, BSN, RN, Henry Jackson Foundation, DVCIPM
RESEARCH STAFF, PVAMC AND UNIVERSITY OF PENNSYLVANIA
Tiffany Huseman, BA
Olivia Antosiewicz, BA
Dana Brown, BS
Shawn Fernandes, BS
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What did we learn?: A Snapshot
• From 381 combat-injured service members studied for 2 years after acute care for their injury, we learned: – Greatest improvement in pain outcomes
occurred in the first 6 months after discharge from the hospital and then remained stable
– Incidence of behavioral health problems (anxiety, depression and Posttraumatic Stress Disorder PTSD) was concerning• 46% of the sample (158 out of 347) had PTDS symptoms
• 14% (48) had severe PTSD
Connection of Practice to Science
Science PracticePractice Science
Military Research is a Compromise: Moving to the Point of Injury• Unable to conduct a study in a Combat Support
Hospital so in 2008, COL Buckenmaier went to Landstuhl Regional Medical Center (LRMC),
Germany
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POWER Survey
Pain Outcomes for Warriors Experiences Research
Pain and Emotional Outcomes During Transport
5.3
6.8
3.5 3.64.1
0
1
2
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8
9
10
Average
pain
Worst pain Anxiety Distress Worry
Better
Worse
Pain Intensity Levels at LRMC
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Themes that Emerged from the Air Evacuation Experience
Content Analysis of Injured
Service Members Experiences
1. Fears
2. Communi-cation
3. Concerns4. Confidence
and Trust
5. Futuristic Visons
Janet A Deatrick,
PhD, RN, FAAN
Desiree A Fleck,
PhD, RN, CRNP
Examples of Expressions of Concerns
• Concerns for others: unit and family
• “I was worried about my, two friends who died and how their wives and kids would do without them. They are both having babies in June.”
• “My guys getting hit by another IED”
• “How my crew was doing two died and one is in the ICU”
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Situating and Forecasting
• Information support
• Practical instruction• “Why did I have to go to Balad from Baghulad where I was
injured? I did not receive medical care in Balad - it seemed like a wasted step.”
• “I wasn’t getting any answers. I know I was going to Germany but after that what?”
• “How long at each place”
• Medical Treatment plans• “When would they fix my arm? Information about my injury”
2009 Camp Bastion Study
• COL Buckenmaier deployed to Camp Bastion, Afghanistan to start an Acute Pain Service (APS) – British military base located in Helmand Province,
southern Afghanistan; a dangerous region– Largest overseas British military installation since World
War II
• Our chance to get real time patient outcomes in a Combat Support Hospital (CSH)
Average Pain Intensity and Percent Pain Relief Scores (N=71)
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4
2.531.3
74.983.1
0
10
20
30
40
50
60
70
80
90
100
0
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Recalled Prehospital
(0-3hrs)
Post Primary Analgesic
Intervention
(4-6hrs)
Prior to Evacuation
(7-24hrs)
Pain Intensity % Pain Relief
% P
ain
Re
lief
Nu
me
ric
Ra
tin
g S
ca
le
Standard deviation bars shown
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19.1%
39.1%
1.5%
5.7%
2.9%
50.0%
31.9%
25.0%
20.3%
32.4%
30.9%
28.9%
73.5%
73.9%
64.8%
0% 20% 40% 60% 80% 100%
Patients managed by APS are
able to be transported sooner
APS pain management
protocols differ markedly fromwhat I usually do
Overall, APS has a significant
impact on patient outcome
Patients managed by the APS
obtain greater levels of painrelief
Patients managed by the APS
report decreased levels ofpain
Strongly Agree and Agree No opinion Strongly Disagree and Disagree
73.5%
30.9%
2.8%
37.7%
19.1%
25.0%
17.4%
24.6%
7.4%
44.1%
79.7%
37.7%
0% 20% 40% 60% 80% 100%
APS needs to improve their
services by providingeducation
Surgical team should determine
what analgesics techniqueshould be used
Regional anesthesia
interventions are too difficult touse in CSH
Complexity of care is increased
with APS involvement
Strongly Disagree and Disagree No Opinion Strongly Agree and Agree
2009: Ketamine Study
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A New Pain Scale for the Military and Veterans Health Administration
• In 2009, the Army Surgeon General chartered the Army Pain Management Task Force to recommend a comprehensive pain management strategy– COL Buckenmair, COL Galloway and Dr.
Gallagher were all leaders in this effort
• Our studies informed this comprehensive report and military policy
• The Task Force's final report contained 109 recommendations – a new pain scale would be designed, tested and implemented
Is pain really what the
experiencing person says it is?
British Military Colleagues
Tested on 350 Services
Members at the Walter
Reed National Military
Medical Center
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Percent Agreementfor Appropriate Placement of Word Descriptors
Intraclass Correlation Coeficient (a
measure of agreement)was > 0.85
A special thanks to Dr. Abby Cohen
The correlation coefficientbetween the two scores was robust and significant, r = 0.93 (P < 0.001), and supported concurrent validity.
This method obtains both concurrent validity and alternate forms reliability.
Concurrent Validity
The Value of the DVPRS: Translation to Practice
• DVPRS provides visual cues and word descriptors to anchor pain ratings with perceptual experiences and limitations imposed by pain
• DVPRS has supplemental questions on general activity, mood, level of stress and sleep to help quantify the impact of pain and screen patients for potential issues
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Patients with neuropathic pain had poorer outcomes.
Dissemination
What is new?Validated Patient-Reported Outcomes (PROs)
PROMIS®: Patient Reported Outcomes Measurement
Information System (PROMIS), funded by the National Institutes of
Health (NIH) ($100 million), is a system of highly reliable, valid,
flexible, precise, and responsive assessment tools that measure
patient–reported health status.
http://www.nihpromis.org/
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Patient Reported
Outcomes
Measurement
Information Systems
Physical Health
Social Health
Mental Health
Global Health