Can Specific Physician Orders about Pain Medications Improve Pain Management in LTC?

1. Can Specific Physician Orders about Pain Medications Improve Pain Management in LTC? Ralf Habermann, MD, CMD (Co-PI) Sumi Misra, MD, MPH, CMD (PI) Tracy Porchak, Project Coordinator Jamie Spicer, GNP Vanderbilt University

2. Faculty Disclosures: Dr. Habermann and Dr. Misra have disclosed that they have no relevant financial relationships.

3. Acknowledgements: • Vanderbilt University, School of Medicine, Center for Quality Aging • John F. Schnelle, PhD • Sandra F. Simmons, PhD • AMDA/Pfizer Quality Improvement Award

4. Background • Pain is prevalent in LTC • Pain assessment is required as a 5th vital sign • Pain is often undetected and untreated, even though most (>90%) LTC residents are able to reliably answer pain questions • LTC Residents are often not given the choice of PRN pain medication References: 1. Chu L. et.al. JAGS 2004, 52:2057-2061. 2. Cadogan M et.al. J Geron:Med Sci, 2004, 59:281-285.

5. Background • Specific physician orders changed nursing home staff behavior for supplement delivery - Between meals instead of w/ meals • May be able to impact other aspects of care References: • Simmons et.al. 2006 JAGS 54(9):1372-1376. • Whiteman et.al. JNHA (in press).

6. Purpose • To determine if specific physician orders about pain medications improve pain management in LTC • How can Physicians improve daily care Quality

7. New Physician Order Ask resident during medication pass: “Do you have pain now?” If resident responds “yes”, ask: “Would you like some medication for it?” If resident responds “yes”, offer choice of PRN pain medication (if necessary in addition to scheduled pain medication) Note: Order was implemented for all med pass delivery periods but night pass was not observed by research staff

8. Methods • One nursing home • Study Inclusion Criteria • Able to self consent (as per IRB) • Order for Pain Medication (Scheduled/PRN) • 53/104 eligible (51% Consent Rate)

9. Demographics (n=53) • Average Age: 83 years (+ 9) • 68% Female • 70% Caucasian • Average Length of Stay: 1.9 years (+ 3.0) • 72% Long-Term Care (remainder sub-acute) • Chart Order for Pain Medications • 63% Order for Scheduled • 96% Order for PRN

10. Most Common Pain-Related Diagnoses • Arthritis: 49% • Stroke: 36% • Osteoporosis: 34% • Cancer: 28% Other Common Diagnoses: • Depression: 51% • Dementia: 36%

11. Methods: Data Collection • 2 Days (morning, afternoon, evening) med pass • Total of 6 observations per person baseline/post • Same Days as Observation: - Resident Interviews about pain - Chart Review (pain medications given)

12. Methods: Timeline • Baseline – 2 observation days week one • New Physician Order immediately after baseline • Post – 2 observation days - Day 1 immediately after order - Day 2 one week after order • Follow-up (in progress) one month after order d/c’d

13. Results: Observations *p<0.05 Note: Numbers reflect percent of observations that question was asked or response was “yes”.

14. Results: Observations *p<0.05 Note: Numbers reflect percent of observations that question was asked or response was “yes”.

15. Results: Chart Review

16. Results: Resident Interview *p<0.05 Note: Numbers reflect percent of “yes” responses.

17. Results: Observation *Note: Total time spent with resident includes care activities beyond med pass

18. Results Summary • Nurses asked residents questions about pain during medication passes more frequently following the new order. • Residents expressed pain more frequently in response to nurses’ questions. • Residents asked for pain medication more frequently in response to nurses’ questions.

19. Results Summary • It required one extra minute per resident/pass to ask questions and provide medication. • Residents’ noticed the difference in nurse behavior. • Most residents expressed a stable preference to take medication for pain. • The number of PRN pain meds increased

20. Implications • Specificity of physician orders may improve care in other areas • Trial of toileting assistance for incontinence • Walking assistance to/from dining room • Offering residents choice during daily care • CHF management i.e. diuretic dose depending on daily weight

21. Barriers to Improvement • Inadequate staffing to provide care consistent with order • Staff Resistance • Variance in nurse pain assessment and treatment - Limits care to specific time of day or protocol • Survey Compliance Risk - Documentation will show care was not provided as ordered

22. Study Limitations • Only one nursing home site. • Short time frame for evaluation (< 1 month) • Residents most at risk for undetected and untreated pain (more cognitively impaired) were not included even though these residents are able to respond to nurse questions ( due to IRB concerns)

23. Future • Development of specific facility wide protocol order set • Inclusion of all residents in this program • Reduction of potential for nurses bias regarding pain medication

24. Conclusion • YES • Physician orders have an impact and can change institutional behavior