Development & Implementation of

“Sliding Scale”Pain Protocols

Jayne Pawasauskas, PharmD, BCPSClinical Professor

URI College of Pharmacy&

Clinical Pharmacy Specialist – Pain Management Kent Hospital

Objectives for Today

To describe the development and implementation of protocols developed to manage acute pain for patients admitted to a medical service

After participating in this presentation, you should be able to: Discuss the rationale for implementation of

acute pain protocols that can be effective for both opioid naïve and varying degrees of opioid tolerant patients

Demonstrate how use of acute pain protocols facilitates compliance with Joint Commission standards and regulations

Drivers for Change Joint Commission

Sentinel Event Alert Prevention of errors Prevention of duplicate orders

Encourage use of Multimodal Approach (MMA) Limit occurrence of opioid-related ADEs

(ORADEs) Our hospital specifics/background

sometimes poor opioid conversions during TOC Provide consistent analgesia Wish list: improve patient satisfaction (HCAHPS

scores)

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Background Information on the Protocols

Created from analysis of inpatient opioid usage/requirements in non-surgical patients Total amount of opioid used by patients in a

variety of medical states on first day of admission, then followed for 10 days or until discharge.

Sample patients did not require naloxone at any point during hospitalization

Sample deemed to have safe and effective use of opioids

Surveillance Data

=> High Dose

The 6 Acute Pain Protocols

Breakpoints were set to distinguish 3 groups of patients: Low dose (0-50 MED per day or opioid naïve) Medium dose (51 – 100 MED per day)

Patient continues on home med of long-acting analgesic and uses this protocol to manage breakthrough pain

High dose (>100 MED per day) Patient continues on home med of long-acting analgesic and

uses this protocol to manage breakthrough pain

For each of these dose ranges, there is a regular/normal PowerPlan, and one for NPO patients

Each protocol contains 3 steps of analgesia (and medications): mild (any pain >0), moderate (pain 4-7), and severe (pain 8-10)

LowDose Protocol

High Dose Protocol

High Dose NPO

Link to Global RPh

Preliminary Data

Initial 90 days after implementation

Plan # patients (%)

Low dose 58 (84.1%)

Low dose NPO 5 (7.3%)

Medium dose 4 (5.8%)*

Medium dose NPO

1 (1.4%)

High dose 1 (1.4%)

High dose NPO 0

* One occurrence of medium dose protocol ordered on an opioid-naïve patient

No other overt errors encountered with selection of appropriate protocol forIndividual patient

Indications

Pharmacist interventions

Documentation of pharmacist interventions for 13% of patients Therapeutic duplication Tramadol issues (additive seizure risks with

other meds on profile, fall risk) Clarify home med vs. protocol med Drug Allergy General questions

Subgroup Analysis

Exlusion criteria Patient received less than 2 doses of pain

protocol med/24 hr Patient admitted to ICU at any time during

hospitalization Surgical patient/post-op Excluded nursing unit (4W or 2N)

N=26 Representing 12 different hospitalist

prescribers

Efficacysubgroup analysis of patients meeting study inclusion criteria (n=26)*

Baseline pain score Average = 7.13 Median = 7

17% were opioid tolerant Time to analgesia

Average = 7.5 hr Median = 4.35 hr

* 2 patients excluded from analgesia analyses due to problems with documentation of pain scores

Safety Use of naloxone 0 GI ADRs

3 patients had documented episodes of diarrhea No additional treatments needed

C.diff 2 patients tested

One negative – admitted for Abd. Pain/diarrhea prior to use of protocols

One positive – admitted with h/o C.diff

Constipation 1 patient had documented constipation

Administered enema; addition of senna/docusate BID, bisacodyl PR prn

Nausea/Vomiting 6/5 patients – received additional ondansetron or

prochlorperazine Most patients had admitting diagnosis contributing to N/V

(i.e. EtOH withdrawal, n/v, infections, cancer)

Potential Pitfalls….

Correlation of breakthrough pain medication to numeric pain scores ?indications becoming too specific?

Incorrect use could create duplications PowerPlan on profile + additional

opioids ordered Pharmacists must be very careful when

reviewing new orders for analgesics

Questions?