Part I

Telling the Patientrsquos Story About Acute Pain

November 2017

Objectives

Outline the process for screening assessing and reassessing pain from an emergency department visit to admission as an inpatient

Explain the criteria for determining the appropriate pain assessment tool

Identify risk factors that increase the likelihood for respiratory depression for patients receiving opioids

Discuss content and the resources available for patientfamily education on pain management

Demonstrate empathy for patients experiencing pain

Pain Assessment

Patientsrsquo Experiences with Pain

11-20 of surgical patients experience moderate to severe pain

Self report is the most reliable indicator of pain

Assess nonverbal indicators associated signs and symptoms along with self-report to fully understand degree of pain

Family members may be helpful to determine degree of pain for patients with dementia

Ineffectively treated pain may lead to persistentchronic pain

Joint Commission Standards Screening and AssessmentThe Hospital-

Uses methods that have defined criteria to screen assess and reassess pain that are consistent with the patientrsquos age condition and ability to understand

Screens patients for pain during emergency department visits

Elements of Pain Assessment

Standards for Inpatient Units amp the Emergency Center at Methodist Hospital Pain goal Location Onset Intensity Quality Richmond Agitation Sedation Scale (RASS) Aggravating factors Relieving factors Pain management interventions

Pain Assessment

When to complete Admission Hand-offs (shift and between departments) Onset of newly identified pain Worsening pain Interventions not providing adequate relief Change in level of care Based on unit routines

Use Appropriate Pain Assessment ToolMake sure tool choice is consistent with age condition and ability to understand Numerical Rating Scale (0-10) Wong Baker Faces Scale Neonatal Infant Pain Scale (NIPS) birth to 4 weeks Face Legs Activity Cry Consolability Scale (FLACC)2

months to 7 years Critical Care Pain Observation Tool (CPOT) Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Objectives

Outline the process for screening assessing and reassessing pain from an emergency department visit to admission as an inpatient

Explain the criteria for determining the appropriate pain assessment tool

Identify risk factors that increase the likelihood for respiratory depression for patients receiving opioids

Discuss content and the resources available for patientfamily education on pain management

Demonstrate empathy for patients experiencing pain

Pain Assessment

Patientsrsquo Experiences with Pain

11-20 of surgical patients experience moderate to severe pain

Self report is the most reliable indicator of pain

Assess nonverbal indicators associated signs and symptoms along with self-report to fully understand degree of pain

Family members may be helpful to determine degree of pain for patients with dementia

Ineffectively treated pain may lead to persistentchronic pain

Joint Commission Standards Screening and AssessmentThe Hospital-

Uses methods that have defined criteria to screen assess and reassess pain that are consistent with the patientrsquos age condition and ability to understand

Screens patients for pain during emergency department visits

Elements of Pain Assessment

Standards for Inpatient Units amp the Emergency Center at Methodist Hospital Pain goal Location Onset Intensity Quality Richmond Agitation Sedation Scale (RASS) Aggravating factors Relieving factors Pain management interventions

Pain Assessment

When to complete Admission Hand-offs (shift and between departments) Onset of newly identified pain Worsening pain Interventions not providing adequate relief Change in level of care Based on unit routines

Use Appropriate Pain Assessment ToolMake sure tool choice is consistent with age condition and ability to understand Numerical Rating Scale (0-10) Wong Baker Faces Scale Neonatal Infant Pain Scale (NIPS) birth to 4 weeks Face Legs Activity Cry Consolability Scale (FLACC)2

months to 7 years Critical Care Pain Observation Tool (CPOT) Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment

Patientsrsquo Experiences with Pain

11-20 of surgical patients experience moderate to severe pain

Self report is the most reliable indicator of pain

Assess nonverbal indicators associated signs and symptoms along with self-report to fully understand degree of pain

Family members may be helpful to determine degree of pain for patients with dementia

Ineffectively treated pain may lead to persistentchronic pain

Joint Commission Standards Screening and AssessmentThe Hospital-

Uses methods that have defined criteria to screen assess and reassess pain that are consistent with the patientrsquos age condition and ability to understand

Screens patients for pain during emergency department visits

Elements of Pain Assessment

Standards for Inpatient Units amp the Emergency Center at Methodist Hospital Pain goal Location Onset Intensity Quality Richmond Agitation Sedation Scale (RASS) Aggravating factors Relieving factors Pain management interventions

Pain Assessment

When to complete Admission Hand-offs (shift and between departments) Onset of newly identified pain Worsening pain Interventions not providing adequate relief Change in level of care Based on unit routines

Use Appropriate Pain Assessment ToolMake sure tool choice is consistent with age condition and ability to understand Numerical Rating Scale (0-10) Wong Baker Faces Scale Neonatal Infant Pain Scale (NIPS) birth to 4 weeks Face Legs Activity Cry Consolability Scale (FLACC)2

months to 7 years Critical Care Pain Observation Tool (CPOT) Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Patientsrsquo Experiences with Pain

11-20 of surgical patients experience moderate to severe pain

Self report is the most reliable indicator of pain

Assess nonverbal indicators associated signs and symptoms along with self-report to fully understand degree of pain

Family members may be helpful to determine degree of pain for patients with dementia

Ineffectively treated pain may lead to persistentchronic pain

Joint Commission Standards Screening and AssessmentThe Hospital-

Uses methods that have defined criteria to screen assess and reassess pain that are consistent with the patientrsquos age condition and ability to understand

Screens patients for pain during emergency department visits

Elements of Pain Assessment

Standards for Inpatient Units amp the Emergency Center at Methodist Hospital Pain goal Location Onset Intensity Quality Richmond Agitation Sedation Scale (RASS) Aggravating factors Relieving factors Pain management interventions

Pain Assessment

When to complete Admission Hand-offs (shift and between departments) Onset of newly identified pain Worsening pain Interventions not providing adequate relief Change in level of care Based on unit routines

Use Appropriate Pain Assessment ToolMake sure tool choice is consistent with age condition and ability to understand Numerical Rating Scale (0-10) Wong Baker Faces Scale Neonatal Infant Pain Scale (NIPS) birth to 4 weeks Face Legs Activity Cry Consolability Scale (FLACC)2

months to 7 years Critical Care Pain Observation Tool (CPOT) Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Joint Commission Standards Screening and AssessmentThe Hospital-

Uses methods that have defined criteria to screen assess and reassess pain that are consistent with the patientrsquos age condition and ability to understand

Screens patients for pain during emergency department visits

Elements of Pain Assessment

Standards for Inpatient Units amp the Emergency Center at Methodist Hospital Pain goal Location Onset Intensity Quality Richmond Agitation Sedation Scale (RASS) Aggravating factors Relieving factors Pain management interventions

Pain Assessment

When to complete Admission Hand-offs (shift and between departments) Onset of newly identified pain Worsening pain Interventions not providing adequate relief Change in level of care Based on unit routines

Use Appropriate Pain Assessment ToolMake sure tool choice is consistent with age condition and ability to understand Numerical Rating Scale (0-10) Wong Baker Faces Scale Neonatal Infant Pain Scale (NIPS) birth to 4 weeks Face Legs Activity Cry Consolability Scale (FLACC)2

months to 7 years Critical Care Pain Observation Tool (CPOT) Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Elements of Pain Assessment

Standards for Inpatient Units amp the Emergency Center at Methodist Hospital Pain goal Location Onset Intensity Quality Richmond Agitation Sedation Scale (RASS) Aggravating factors Relieving factors Pain management interventions

Pain Assessment

When to complete Admission Hand-offs (shift and between departments) Onset of newly identified pain Worsening pain Interventions not providing adequate relief Change in level of care Based on unit routines

Use Appropriate Pain Assessment ToolMake sure tool choice is consistent with age condition and ability to understand Numerical Rating Scale (0-10) Wong Baker Faces Scale Neonatal Infant Pain Scale (NIPS) birth to 4 weeks Face Legs Activity Cry Consolability Scale (FLACC)2

months to 7 years Critical Care Pain Observation Tool (CPOT) Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment

When to complete Admission Hand-offs (shift and between departments) Onset of newly identified pain Worsening pain Interventions not providing adequate relief Change in level of care Based on unit routines

Use Appropriate Pain Assessment ToolMake sure tool choice is consistent with age condition and ability to understand Numerical Rating Scale (0-10) Wong Baker Faces Scale Neonatal Infant Pain Scale (NIPS) birth to 4 weeks Face Legs Activity Cry Consolability Scale (FLACC)2

months to 7 years Critical Care Pain Observation Tool (CPOT) Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Use Appropriate Pain Assessment ToolMake sure tool choice is consistent with age condition and ability to understand Numerical Rating Scale (0-10) Wong Baker Faces Scale Neonatal Infant Pain Scale (NIPS) birth to 4 weeks Face Legs Activity Cry Consolability Scale (FLACC)2

months to 7 years Critical Care Pain Observation Tool (CPOT) Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment Tools

Numerical Rating Scale

Wong Baker Faces Scale

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment Tools

Neonatal Infant Pain Scale (NIPS) birth to 4 weeks

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment Tools

Face Legs Activity Cry Consolability Scale (FLACC) 2 months to 7 years

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT)

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment Tools

Pain Assessment in Advanced Dementia Scale (PAINAD)

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Documentation of Pain Assessment within EPIC

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Case Study Acute Pain

A 72 year old woman is admitted with cellulitis of RLE States the throbbing pain has gotten worse over the last 2 days with the swelling and redness making it difficult to sleep and walk

She rates the pain as 710 with increasing pain when trying to ambulate Pain at rest is 310 Goal is for pain to be 110 ldquoI canrsquot take this painrdquo

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment-Case Study

Inpatient EPIC View

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment Case Study

EC EPIC view

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Assessment and Management Use of Opioids

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Joint Commission Standard

The Hospital- Monitors patients

identified as being high risk for adverse outcomes related to opioid treatment

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Adverse Drug Events-Opioids

ldquoOpioid-induced respiratory depression has resulted in deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoringrdquo (CMS 2014)

Of all the opioid-related adverse drug that occurred in hospitals (2004-2011) 29 were related to improper monitoring of the patient (Joint Commission 2012)

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Risk Factors for Respiratory Depression in Patients receiving Opioids There is sufficient evidence that has demonstrated sleep-

disordered breathing and pulmonary complications (eg atelectasis pneumonia and respiratory failure) in the postoperative period are individual risk factors that increase the risk of respiratory depression 4

Some examples of other factors that may impact respiratory depression include smoker (gt20 pack-years) prolonged surgery (gt2 hours) concomitant administration of sedating agents such as benzodiazepines or antihistamines age greater than 55 Individually these factors have weaker evidence4

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Partnering with Patients Plan for Pain Management

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Joint Commission Standard

The Hospital- Involves patients in the pain management Develops realistic expectations and measurable goals that are

understood by the patient Discusses the objectives used to evaluate treatment progress

(for example relief of pain and improved physical and psychosocial function)

Provides education on pain management treatment options resuming activities after discharge and safe use of opioid and non-opioid medications when prescribed

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Patient Experiences with Pain at Methodist Hospital Patient satisfaction is associated with effectiveness of pain

control ldquohellip itrsquos so fatiguinghellipit takes a lot out of yourdquo ldquoI was expecting it Staying on top of it with medication is

importantrdquo ldquohellipeveryone is different with pain medications I kept telling staff

that it wasnrsquot workinghellip Listen to the patientrdquo

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

PatientFamily Education about Pain Management Explain options for pharmacological

and non pharmacological interventions

Explain side-effects and effectiveness of pain intervention What are they How long will they last What can be done to reduce

Educate on when to notify staff promptly

On available units utilize GetWell) pain education video

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Strategies to Manage Pain and Reduce Adverse Effects Start low go slow

Multi-modal approach Use non

pharmacological interventions

Opioids Non-steroidal Tylenol and adjuvants

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Use of non-pharmacological interventions

Positioning Hand massage (HELP

volunteers and chaplains) Warmth or cold Music Distraction Relaxation Aromatherapy Pet Therapy

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Therapeutic Duplication

What is Therapeutic Duplication The practice of prescribing multiple medications (prn) for the

same indication or purpose without a clear distinction of when one agent should be administered over another

Why is this an issue Potential risk for over-sedation related to pain medications To practice within an RNrsquos professional scope clinicians must

provide parameters on which medications are to be given based on type and degree of pain (prn medications)

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Plan to Reduce Therapeutic Duplication

Clinician Role Order set has individualized

prn pain medications linked to a numerical score

mild (1-4) moderate (5-7) or severe (8-10)

Nursing implication Describe type and severity

of patientrsquos pain to clinicians enabling them to prescribe consistent with mild-moderate-or-severe scores

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Plan to Reduce Therapeutic Duplication

Pharmacy

Will review PRN opioid orders for therapeutic duplication and make changes to orders

OR Will communicate with clinicians to make changes as

needed For example if there are 2 orders for PRN Dilaudid IV

each order will need to give direction as to when to give each of the different dosesroutefrequency or discontinue one of the orders (eg oral vs IV mildmoderatesevere do not give IV and oral at same time etc)

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Plan to Reduce Therapeutic DuplicationNursing Pain assessment score must match the parameters

(mildmoderatesevere) of the PRN pain medication order

Nurse must contact clinician for a new order if prn order does not meet the needs of the patient For example if patientrsquos pain rating is a ldquo6rdquo and the only

PRN opioid medication ordered is Dilaudid (03-05 mg) IV every 3 hours for severe pain (8-10) then the nurse would need to call the clinician for a new order

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Reassessment

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Joint Commission Standard

The Hospital reassesses and responds to the patientrsquos pain through Evaluation and

documentation of response to pain interventions

Progress toward pain management goals (intensity and function)

Side effects of treatment

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Reassessment Standard at Methodist Hospital Elements of reassessment Pain relief Side Effects of intervention Patient satisfaction with treatment

Within 60 minutes of pharmacological intervention Nursersquos clinical judgement With change in pain status

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Reassessment Standard at Methodist Hospital When patient is asleep Assess respirations Use pulse oximetry (spot check vs continuous) Charting that a patient is asleep is not a sufficient

reassessment

On units with GetWell) once a pain medication is pulled from Pyxis the patient will receive a prompt 45 minutes later asking them to rate their pain level THIS DOES NOT QUALIFY as your pain reassessment

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Reassessment

Pain reassessed within 60 minutes Pain rating and nonverbal and description included

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Pain Reassessment Monitoring

Include RASS (Richmond Agitation and Sedation Score) while patient is awake in documentation when administering PRN opioids

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Hand-offs Pain Management is an Essential Component

PACU or EC to Floor RN (SBAR)

Shift change breaks Between other members of

care team ( PTOT NA MD and etc)

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

It Takes a Team to Manage Pain

Patients Hospitalists Palliative Care Clinicians Volunteers Therapies Nursing Staff (RN amp NA)

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Patient and Family Resources for Pain Management and EducationHealthwise Acute Pain After Surgery Developing a Pain Management Plan Chronic Pain Learning About Opioids

Pharmacy Provide verbal andor written information about pain

management including safe use storage and disposal of opioids when prescribed at discharge Discuss resuming activity in relation to pain prior to discharge

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Nursing Resources for Pain Management and EducationClinical Skills (Mosby)Search the following terms Pain Assessment and Management Pain Assessment and Management (Neonatal) Pain Assessment Scales and Management (Pediatric) Comfort Promotion Distraction (Pediatric) Comfort Promotion Guided Imagery (Pediatric)

Acute Pain Management PolicyGetWell)

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

Improving Pain Management ndashHelps Us to Achieve the Triple Aim Improved patient experience with pain control Reduced cost if pain managed to prevent extended length of

stay Improved outcomes by managing pain with appropriate

medications reducing adverse side effects and potential long term effects of ineffective pain management

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January

References1 Center for Medicare and Medicaid 2014 Standards for Hospital Medication

Administration Particularly IV Medications and Post-operative Care of Patients Receiving IV Opioids

2 The Joint Commission Perspectives (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals 37(7)1-3

3 httpwwwgeriatricpainorgaccessed April 20154 Jarzyna DJungquist C PaseraC et al (2011) American Society for pain

management guidelines on monitoring for opioid-induced sedation and respiratory depression Pain Management Nursing 12(3) 118-145

5 The Joint Commission (2014) Standard PC010207 Comprehensive accreditation manual for hospitals The official handbook Oakbrook Terrace IL The Joint Commission

6 ThorsonD BiewenP et al (2014) Acute pain assessment and opioid prescribing protocol Institute for Clinical Systems Improvement (ICSI) January