Advancing Excellence Campaign: Improved Pain Management in Skilled Nursing Facilities

1. Advancing Excellence Campaign: Improved Pain Management in Skilled Nursing Facilities An Examination of the Nature and Adverse Effects of Pain and Guidelines for Improved Pain Management for Both Long and Short Term Nursing Home Residents. Edited by: Laura McNamara, APRN-BC, ANP, GNP, ACHPN

2. Goals For Pain Management For Long Term Nursing Home Residents, Average of Moderate to Severe Pain Experienced will be at or below 4%. For Short Term Nursing Home Residents, Average of Moderate to Severe Pain Experienced will be at or below 15%.

3. Challenges of Pain Analysis • Complex and Multi-factorial • Identifying specific causes my be difficult • Often subtle and nonspecific • “Referred Pain” can be misleading • Subjective vs. Objective mismatches • Nociceptive versus Neuropathic pain • Communication issues with both impaired and intact residents of SNFs.

4. Challenges of Pain Management • Knowledge Deficits • Time/Support Constraints • Communication Demands with Patient, Family, Physician/NP, RN Colleagues, Nursing Aides and Ancillary Service Staff • Evaluation and Measurement of Pharmacological Analgesia, including Adverse Effects • Familiarity of Non-Pharmacological Treatments and follow-up evaluation and measurement

5. Adverse Effects of Untreated/Undertreated Pain • Negative Impact upon Health/Quality of Life • Slowed Rehabilitation • Increased Depression • Increased Anxiety • Increased Social Isolation • Increased Cognitive Impairment • Increased Immobility, Gait Disturbance • Increased Sleep Disturbance • Spiritual Despair • Disease Progression • Increased Pain Sensitivity • Increased Health Care Utilization and Costs

6. Typical Signs of Acute Pain • Hyperactivity of the sympathetic nervous system: • Elevated blood pressure • Elevated respiratory rate • Tachycardia • Diaphoresis • Dilated pupils • Agitation/Physical Movements/Vocalizations

7. Complicated/Subtle/Multifactorial Signs of Persistent Pain • Vegetative Signs: • Listlessness • Decreased Appetite/Loss of Taste for Food/Weight Loss • Constipation • Sleep Disturbance • Social Withdrawal • Psychological Impairment • Functional Impairment and Disability

8. Complicated/Subtle/Multifactorial Signs of Persistent Pain (Continued…) • Agitation and Anxiety • Frequent Verbalizations • Frequent Agitated Movements • Increased Depression and Anxiety • Refusal of Care • Defensive Behaviors • Overwhelming Self Focus • Preoccupation with Physical Status

9. Let’s Get Started! • Need to Evaluate What Tools are in Place to Evaluate Pain and Implement Improved Pain Management: • Establish “Buy-In” with establishment of Focus Group with Members from CNAs, MDS and Staff RNs, Nursing Management, MD/NPs and Spiritual Providers. • Review current measurements, strengths and weaknesses.

10. Review of Standards of Care • Provide Authoritative Information related to Pain in the Elderly/Residents of Nursing Homes: • AMDA Guidelines • AGS Pain Guidelines • Hartford Foundation Compare current tools in place to available expert resources and adjust/readjust SNF Pain Assessment and Management System/Processes

11. Room for Improvement… • Identify Barriers to quality pain assessment and management • Review Current Practices, evaluating for deficits and areas of improvement • Review Cases/Issues that have been previously identified r/t identifying and managing pain

12. Frame Work Establishment • Implement Tools for Evaluation of Pain • Provide Information/Training in Tools for Evaluation of Pain (Nociceptivevs Neuropathic vs Mixed) in Cognitively Intact and Cognitively Deficient Residents of Nursing Homes • Implement Tools for the Treatment of Pain • Review of Standards/Guidelines for treatment of Nociceptive, Neuropathic or Mixed Pain, including both Pharmacological and non-Pharmacological modalities.

13. PAIN ASSESSMENT TOOLS • VISUAL ANALOG SCALES • Wong-Baker FACES Pain Scale • Visual Analog Color-Coded Scale • NUMERICAL RATING PAIN SCALE • McGill Pain Scale for Pain Assessment • PQAS Scale • Numerical and Comparative Pain Scale • VRS and NRS • OBSERVATIONAL PAIN SCALES • COMFORT Scale • PLACC Scale • CRIES Scale • Observer Rated Pain Scale • NVP Scale

14. Provide Education, Resources, Support and Feedback • Arrange presentations on Nature of Pain, Evaluation Tools, and Treatment Modalities • Arrange easily accessible printed materials for review and use • Assign a “point person” or expert in Pain Management who can consult/assist as needed on challenging cases • Provide and Seek prompt feedback r/t specific cases, and overall progress

15. Invest in the System and Individual • Evaluation of Systemic Approach ongoing • What tools are cumbersome/not working • Limitations of RN guided treatment • Evaluation of Personal Approach as well… • Knowledge Deficits • Past Personal Experience vs. “Expert” Opinion • Personal Biases r/t Pain • Fear of Negative Consequences

16. Continuous Monitoring • Pain Recognition • Every Resident Must Be Considered • Pain Assessment • Acute, Persistent, Nociceptive, Neuropathic, Mixed • Emotional, Psychological and Spiritual Pain • Cause Identification and Diagnosis • Challenges Inherent in Residents with Dementia • Special Challenges Inherent in Complicated Personalities • Management and Treatment • Pharmacological Agents • Non-Pharmacological Agents And Continuous Monitoring!

17. Strengths and Weaknesses • Evaluate Concrete Data • Patients with pain • Patients with well managed pain • Evaluate Nursing Knowledge and Satisfaction • Current Knowledge of Tools • Current Knowledge of Available Resources • Satisfaction with skill/knowledge growth • Satisfaction with high skill level/quality of care of both short and long term residents

18. Goals for Recognition/Assessment • Intitial Assessment within 24 hours of Arrival or Condition Change • Regularly Scheduled Reassessment and Monitoring of Pain Intensityand Quality in the Physical Health, Social, Emotional and Spiritual Context • Consider Each Resident as Individual, but with many possible similarities, i.e., Osteoarthritis is the number one cause of pain in the elderly. Appropriate Documentation of Assessment

19. Details, details, details… • In Challenging Residents, the “odd” details often point the way to better treatment. • Indepth Discussion/Communication with resident, family, colleagues, support staff, ancillary service staff, and providers may be necessary in residents with partial or limited improvement with treatments in place or the use of high risk analgesia/possible adverse effects of treatment complicating pain/comfort issues.

20. Documentation • Telling “the story” • Presenting the “facts” • Giving some background information • Providing Interpretation • Use of forms (scales), but need for narrative • Close monitoring and documentation of treatment modalities and effects: positive, negative and neutral

21. MDS Documentation • Section J0100: Pain Management over the last 5 days to be completed. • Scheduled pain regimen: narcotic/NSAIDs/Acetaminophen (non-pathway analgesia not included). • PRN pain medication use. • Non-pharmacological interventions for pain • Further documentation concerning communication deficient residents and non-verbal s/s of pain (“Staff Observation of Pain”). • Further evaluation at 14, 30, 60, and 90 day points ESSENTIAL: important quality indicators for DPH.

22. INFORM AND DISCUSS • Communicate findings to MD/NP: • Periodically • With every change in treatment plan after a reasonable period of time • With new symptom development that may represent further pain • When important additional information becomes available • When current interventions do no appear to be adequate • When causes of pain and effect of treatment plan remain unclear/need further exploration

23. Identify Pain Management Goals • Collaboration is needed with resident, family, Nursing Staff and Practitioner in the establishment of goals • Ideally, underlying cause of pain should be addressed, but is not always possible to resolve • Goals can be adjusted to achieving a reduction of pain to a tolerable level • Goals may need to be adjusted over time, as causes/prognosis/effectiveness of interventions evolve. • Recognize there may need to be tradeoffs between pain control and undesirable treatment effects.

24. Managing Pain • Nursing Staff and MD/NP work together to review causes/characteristics of a resident’s pain. • Nursing Staff has gathered enough information to help inform the treatment plan. • Nursing Staff and MD/NP implement plan to manage pain and possible adverse symptoms/effects of plan. • Use of Pertinent Protocols and Guidelines, or clinically warranted alternate treatment plan

25. Pain Management Options • Non-pharmacological options used alone or in conjunction with analgesia • Heat, cold, positioning, distraction, massage, baths, behavioral/psychological therapies, environmental modifications, exercise, music therapy, OT/PT, pet therapy, prayer, relaxation techniques, therapeutic use of self. • Consideration of possible adverse effects • Pharmacological options • Use of the WHO’s Pain Relief Ladder • Consideration of possible adverse effects

27. Analgesia • First line for mild generalized, nonspecific or osteoarthritic discomfort is Acetaminophen. • Periodically monitor LFTs, caution w/liver disease • Possible to use NSAIDs short term for inflammation,musculoskeletal conditions. • Adverse GI effects, Cardiovascular and Renal Risks • Opioidsare used for moderate to severe pain, both short-acting and extended release. • Extensive adverse side effects, including delirium, urinary retention, constipation, nausea, gait instability, sedation, respiratory depression • Adjunct Therapies, including anticonvulsants, antidepressants, steroids, alpha-2-adrenergic agonists, local anesthetics, NSAIDs, topical (nonsystemic) drugs. • Adverse side effects can affect the GI, urinary, and nervous system, as well as a resident’s psychological/mental status

28. Reassess and Adjust • Continuous Process • Must Include Treatment Adjustments for Adverse Side Effects • Consider Changes in Health/Physical Condition with Acute Changes in Pain Status • Continuous Involvement of CNAs, Staff RNs (all shifts), Nursing Supervisors. Continuous intermittent Involvement of DON/A-DON, MDS, MD/NP, and Ancillary Services Staff.

29. Challenges Must Be Expected… • When a resident continues to have unacceptable pain/symptoms despite multiple interventions • When increased medication doses do not seem to bring relative relief • When MD/NP is not readily available or not helpful • When it remains unclear if a resident’s symptoms truly represent pain • When pain levels remain elevated despite best efforts • When adverse events occur despite close monitoring

30. And Met with Further Education, Reassessment and Adjustments! • It is our responsibility to take care of our residents and to ease their suffering. • Nurses and CNAs are residents’ best advocates. • Families must be considered in the equation. • The guiding principle of doing no harm must be balanced with providing comfort/alleviating pain and suffering. • The therapeutic use of self by Nursing Staff is an underutilized and rarely recognized tool in the easing of suffering. Intention and caring are meaningful entities, and when combined with skill and education, they possess a powerful force of good for our patients.