Pain Management During Wound Dressing Changes

1. Pain Management During Wound Dressing Changes Alex Fay, Michael Frederick, Brent Sugimoto, Jed Wolpaw PISCES Quality Improvement Project UCSF School of Medicine Class of 2010

3. Question • Can we change systems of care to facilitate premedication of surgical patients prior to wound dressing changes? Can we do something to improve pain management during dressing changes in the hospital?

4. Outline • Is solving the problem beneficial? • Is Pain Control Good? • Who does the protocol benefit? • Who are the stakeholders? • Do they support the intervention? • What is the impact on the individual stakeholders? • What is the plan? • Why this intervention and not others? • Is the plan feasible? • Implementation & Evaluation • Future directions. . .

5. Is Pain Control Beneficial? - Personal experience/Anxiety8 - Virtual Reality Relaxation1,9 YES! Expectation Satisfaction Pain Control • Satisfaction survey11 • Pain Scale12,14 • Improved outcomes15,16,17,18 • - Acetaminophen, NSAIDS, Opioids • PO, IV6, intranasal4, PCA3, patch2 • Topical/Dressing5,7,10 • Alternative therapies13 11Carrougher et al (2003); 16Perkins et al (2000)

6. Who does the protocol benefit? • The patient! • Others • Doctors, Nurses & Health Staff • The Medical Center

7. Stakeholder Consultation

10. NUMBER OF INTERVIEWS

11. Survey - Attitudes • How important to you is pain control for wound dressing changes • (1) Not Very (10) Very Important • Is pain management during dressing changes a problem? Please explain. • How frequently is pain management during wound dressing changes a problem? • (1) Almost Never (10) Almost Always

12. Survey – Current Practice What do you currently do to prevent pain during dressing changes? How do you evaluate when measures are or are not needed for pain control during dressing changes, if ever? What are other options for pain control with dressing change?

13. Survey – Current Practice What is your role in the process? Who are other people you can identify, who affect this process? What obstacles do you encounter in preventing pain during dressing changes?

14. Survey - Feasibility • What barriers can you identify to its implementation? • Please identify anyone—from patients, to health staff, to administrators—who would be concerned about the implementation of this new protocol. • Imagine UCSF began requiring adequate pain control administration 15 minutes prior to dressing changes. Please rate the feasibility of this new protocol in your practice (1) Impossible (10) Easily to Implement Implemented

15. Survey Results

16. Survey Results • How Important to you is pain control for wound dressing changes? (1 = Not important; 10 = Very important) • Surgeon (4): 8.875 • Resident (4): 8.5 • Nurse (5): 10 • Patient (5): 9 • How frequently is pain management during dressing changes a problem? (1 = Almost Never; 10 = Almost Always) • Surgeon (4): 4 • Resident (4): 4.5 • Nurse (5): 4.5 • Patient (5): 4.2 • Not a problem when: • Patient unconscious, intubated, epidural • Adequate pain meds are given • Patient tolerates pain (patient-to-patient variability)

17. Survey Results CURRENT STRATEGIES FOR PAIN PREVENTION • Pain medications, PCA, epidural • Gentle dressing removal • Counseling, deep breathing, distraction, anxiety reduction • Call nurse 30 minutes ahead

18. Survey Results OTHER OPTIONS FOR PAIN CONTROL • Conscious sedation, call pain team to bedside, take patient to OR • Relaxation techniques, counseling, anxiolytics • Better planning with team • Involve patient in the process

19. Survey Results ROLES IN DRESSING PAIN MANAGEMENT • Role of Surgeons/Residents: • Advocate for patient, prevent oversedation • Resident: change dressing, order meds, contact ICU/pain teams • Role of Nurses: • Evaluate wound, change sometimes, consult • Initiate conversation about optimal pain management • Others: • RT, Anesthesia, Sedation Nurse, Wound Care Specialist • Students • Family

20. Survey Results FEASIBILITY OF PAIN CONTROL PROTOCOL • “Imagine UCSF began requiring adequate pain control administration 15 minutes prior to dressing changes. Please rate the feasibility of this new protocol in your practice.” • Impossible (10) Easily • to Implement Implemented • Surgeon (n = 4): 5 • Resident (n = 4): 6.5 • Nurse (n = 5): 6.25 • Patient (n = 5): 5.75

21. Survey Results PERCEIVED BARRIERS TO IMPLEMENTATION • Logistics/timing • Senior resident has to see wound • Not necessary for all patients • Assessing pain • Dosing meds appropriately

22. Survey Results SUMMARY OF FINDINGS • All Stakeholders See Pain Control as Important • Pain During Dressing Changes is Inadequately Controlled in Some Patients • All Stakeholders Have Doubts About Feasibility of Mandated Pain Protocol • Reasons: • Logistics (Time, Communication) • Each Patient is Different/How to Assess Individually • Not Necessary in All Cases

23. Survey Results SUMMARY OF FINDINGS • Strategies Already Employed • Call Ahead to Nurse to Pre-Medicate Patient • Epidural Anesthesia • Take Patient to OR • Relaxation Techniques, Anxiolytics • Intervention • Focus on Improving Logistics, Not Education or New Technology

24. Implementation, Evaluation and Future Directions

25. Implementation: Three Parts • C.A.R.E. • Call RN in advance • Ask the nurse to give pain medication • Remove Dressing • Evaluate Pain • ORNurses-Have charge nurses review CARE at each pre-shift meeting • Room/Chart Flag: “Dressing Change Precautions” (like contact precautions)

26. Room & Chart Flags If Patient tells RN, Resident, or Attending that she/he is having pain with dressing changes, room/chart flag is placed, making pain control mandatory 15 minutes before dressing changes.

27. Evaluation • Re-administer the following questions from survey: • Is pain management during dressing changes a problem? • How frequently is it a problem? • Improvement in scores over time will indicate success of intervention

28. Future Directions • Empowering midlevel personnel • NPs or PAs to do dressing changes, possibly with photos or video for attending and residents to review • Anesthesia • Incorporate post-op pain control planning into anesthesia choices • Epidural catheters allow for excellent pain control post operatively

29. Summary • Pain control is important to MDs, RNs, and patients, but inadequately managed in some patients • Current systems barriers impact consistent pain control • There is no preexisting mechanism for ensuring pain control during dressing changes • Using preexisting models and stakeholder consultation, we designed an implementation plan for a three-part intervention • We believe this intervention could improve patient satisfaction and outcomes.

30. Acknowledgments Drs. Tong and McGrath The Nurses, Residents and Attendings who willingly took our surveys The patients who we are privileged to work with and who inspired our project

31. ¿Questions?

32. Bibliography • Konstantatos, A., Angliss, M., Costello, V., Cleland, H., Stafrace, S. Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burn dressings changes. Burns (2008), doi:10.1016/j.burns.2008.08.017 JBUR-2903 • Minkowitz, H., Rathmell, J., Vallow, S., Gargiulo, K., Damaraju, C., Hewitt, D. Efficacy and Safety of the Fentanyl Iontophoretic Transdermal System (ITS) and Inravenous Patient Controlled Analgesia (IV PCA) with Morpine for Pain Management Following Abdominal or Pelvic Surgery. Pain Medicine. (2007) Vol 8, Num 8. • Viscusi E. Patient-controlled drug delivery for acute postoperative pain management: a review of current and emerging technologies. Reg Anesth Pain Med. (2008) Mar-Apr;33(2):146-58. Review. • Finn, J., Wright, J., Fong, J., Mackenzie, E., Wood, F., Leslie, G., Gelavis, A. A randomised coossover trial of patient controlled intranasal fentanyl and oral morphine for procedural wound care in adult patients with burns. Burns (2004) 30;262-268 • Pelissier, P., Pinsolle, V. Post-operative analgesia for open wounds with painful dressings. Burns (2007) 33;131-132. Letter to the Editor

33. Bibliography • Linneman, P., Terry, B., Burd, R.The efficacy and safety of fentanyl for the management of severe procedural pain in patients with burn injuries. J Burn Care Rehabil. 2000 Nov-Dec;21(6):519-22. • Bradley, M. N Cullum. EA Nelson et alia. Systematic reviews of wound care management: (2) Dressings and topical agents used in the healing of chronic wounds. Health Technology Assessment. (1999) 3;17: Part 2. • Sheridan, R., Hinson, M., Nackel, A., Blaquiere, M., Daley, W., Querzoli, B., Spezzafaro, J., Lybarger, P., Martyn, J., Szfelbein, S., Tompkins, R. Development of a Pediatric Burn Pain Anxiety Management Program. J Burn Care Rehabilitation (1997) 18:455-9 • Friesner S, Curry D, Moddeman G. Comparison of two pain-management strategies during chest tube removal: Relaxation exercise with opioids and opioids alone. Heart Lung (2006) 35(4):269-76. • Valenzuela, RC, & Rosen, DA. Topical lidocaine-prilocaine cream (EMLA) for thoracostomy tube removal. Anesthesia and analgesia (1999) 88(5), 1107-8. • Carrougher, G., Ptacek, J., Sharar, S., Wiechman, S., Honari, S., patterson, D., Heimbach, D. Comparison of patient Satisfaction and Self-Reports of Pain in Adult Burm-Injured Patients. J Burn Care Rehabilitation (2003) 24:1-8. • Jensen, M., Smith, D., Ehde, D., Robinson, L. Pain Site and the Effects of Amputation Pain: Further Clarification of the Meaning of Mild, Moderate, and Severe Pain. Pain (2001) 91:317-322

34. Bibliography • Carrougher, G., Ptacek, J., Sharar, S., Wiechman, S., Honari, S., patterson, D., Heimbach, D. Comparison of patient Satisfaction and Self-Reports of Pain in Adult Burm-Injured Patients. J Burn Care Rehabilitation (2003) 24:1-8. • Jensen, M., Smith, D., Ehde, D., Robinson, L. Pain Site and the Effects of Amputation Pain: Further Clarification of the Meaning of Mild, Moderate, and Severe Pain. Pain (2001) 91:317-322 • Jong, A., Middelkoop, E., Faber, A., Van Loey, N. Non-Pharmacological Nursing Interventions for Procedural Pain Relief in Adults with Burns: A Systematic leterature Review. Burns (2007) 33:811-827 • Peiper, B., Langemo, D., Cuddigan, J. Pressure Ulcer Pain: A Systematic Literature Review and National Pressure Ulcer Advisory Panel White Paper. Ostomy Wound Management (2009) Feb;55(2):16-31 • Perkins FM, Kehlet H. Chronic pain as an outcome of surgery: a review of predictive factors.  Anesthesiology. 2000; 93:1123-1133. • Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome.  Anesthesiology. 1995;82:1474-1506. • Wu CL, Fleisher LA. Outcomes research in regional anesthesia and analgesia. Anesth. Analg. 2000;91:1232-1242.

35. Bibliography • Carli F, Mayo N, Klubien K, et al. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology. 2002;97:540-549. • Akca O, Melischek M, Schek T, Hellwagner K, Arkilic CF, Kurz A, Kapral S, Heinz T, Lackner FX, Sessler DI. Postoperative pain and subcutaneous oxygen tension. Lancet 1999;354:41-2.