capa midwest pain society oct 2015.pptx...
TRANSCRIPT
10/26/2015
1
Debra J. Drew, MS, ACNS-BC, RN-BC, AP-PMN
Implementation of the
CAPA©(Clinically Aligned Pain
Assessment) Tool:
Pain is More than Just a Number©
Conflict of Interest Disclosure
• Author’s Conflict of
Interest
No Conflicts of Interest
Objectives
Learners will be able to:
1. Discuss the concept of pain assessment as a
social transaction between patient and
clinician.
2. Summarize the outcomes of University of
Minnesota Health’s implementation of CAPA©.
3. Describe the lessons learned from
implementing a complex and culture-changing
project.
Impetus for Change at University of
Minnesota Medical Center2012
• Low patient pain satisfaction scores (HCAPH)
• Anticipation of effect of Centers for Medicare and Medicaid’s Value-Based Purchasing plan
– Reimbursement based in part on satisfaction with care.
• State of Minnesota, an average of 70% of patients reported satisfaction with pain management scores (MDH, 2014)
• Staff dissatisfied with current numeric pain scale
Are Pain Ratings Irrelevant?
• Noted that fellow pain and palliative care colleagues didn’t always ask about pain intensity using the numeric scale
• In 2015, Short Survey of APS members, N=41
– Pain clinicians do not routinely use pain intensity ratings as part of the pain assessment during clinical practice.
Backonja M & Farrar JT. (2015) Are pain ratings irrelevant? Pain Medicine, 16(7): 1247-1250.
Tide of Thought Shifting
• Reliance on unidimensional scales to guide treatment have been linked to serious adverse events: Increased incidence of opioid over-sedation from 11-24.5/1,000,000 inpatient hospital days.
• Documentation of pain is treated as a regulatory nuisance and clinical decision making is not linked to assessment data.
• Pain is complex and assessment tools need to reflect that complexity, yet be pragmatic in clinical use.
• Pain assessment is a complex communication process between the patient and clinician.
Gordon, DB. Acute pain assessment tools: let us move beyond simple pain ratings. Current Opinion in Anaesthesiology, October 2015, Volume 28 (5), 565-569.
10/26/2015
2
Debate on Self-Report as Gold
Standard in Pediatric Pain IntensityPro:
• Pain is subjective and can only be assessed via self-report
• Guides appropriate treatments.
Con:
• Reliance on self-reported pain scores oversimplify the pain experience,
• Yield only marginal information on which to base clinical decisions,
• Potentially place children at significant risk for adverse events.
Twycross A, Voepel-Lewis T, Vincent C, Franck LS and von Baeyer CL (2015), A debate on the proposition that self-report is the gold standard in assessment of pediatric pain intensity. Clinical Journal of Pain,31(8),707-12.
Pain Assessment as a Social TransactionSchiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676.
• Problem with self-report using a one-dimensional
scale
– Pain is a multi-dimensional complex experience
– Numeric scale difficult for some to use
– Requires linguistic and social skills: problematic
with some of most vulnerable populations
– Patients modulate pain behaviors and self-report
based on their perception of what’s in their best
interest
Patients Modulate Pain ReportsPain Assessment as a Social Transaction
Beyond the “Gold Standard”
• Self-report= gold standard
• Major disconnect between what is advocated and what clinicians actually do
• “Pain is what the patient says it is” acknowledges subjectivity of pain, but ignores complex patient/clinician relationship
• “Pain as 5th Vital Sign” highlights significance of pain, but can be mechanistic
Schiavenato, M & Craig KD. (2010). Pain assessment as a social transaction beyond the “Gold Standard.” Clinical Journal of Pain, 26(8): 667-676.
Pain Assessment as a Social Transaction Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676.
Biological
Sociocultural
Developmental/Psychological
Experience/Empathy
Contextual/Situational
Experience
(Patient Meaning)
Expression Assessment
Judgment
(Clinician Meaning)
Contributing Factors
Assessment Process Patient Clinician
Pain
StimulusInter-
vention
Examples of Contributing Factors in
Pain AssessmentBiologic Sociocultural Developmental-
Psychological
Experience/
Empathy
Contextual/
Situational
Patient Disease,
clinical
condition,
drug
influences
Ethnicity, sex,
access to
healthcare,
cultural
origin
Age, stress, drug
addiction,
interpersonal
skills, fear
Previous
experience
of pain
Language,
fear/stress,
Similarity to
clinician,
socioeconomic
status
Clinician Biologic
disposition,
stress
reactivity
Pt.
preferences
or biases,
age, sex,
education,
ethnic
background
Views on pain,
trust/suspicion,
Interpersonal
skills, critical
evaluation of
pain report
Knowledge,
clinical
competence,
empathy,
institutional
insensitivity
Workload,
interdisciplinary
communication,
facility resources
Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676
10/26/2015
3
Summary of the Social Transaction
of Pain Assessment
Pain assessment best described as a dynamic process, a transaction:
• Intersubjective exchange of meaning between patient and clinician
• Verbal and nonverbal interaction between patient and clinician is modified by the physiologic and social context
• Process dependent on internal/external factors to both parties and environment
News of a New Tool
University of Utah – 2012 Pilot Project
• CAPA© developed to replace conventional numeric rating scale (NRS; 0-10 scale)
• Press Ganey© scores increased from 18th to 95th percentile
• 55% patients preferred CAPA ©
• Nurses preferred CAPA © 3:1 over NRS
From, Donaldson & Chapman, 2013.
Clinically Aligned Pain Assessment (CAPA)
“Pain is More Than Just a Number” ©
• Evaluates
– intensity of pain
– effect of pain on functionality
– effect of pain on sleep
– efficacy of therapy
– progress toward comfort
• Engages patient and clinician in a brief conversation about pain resulting in coded evaluation
From, Donaldson & Chapman, 2013.
CAPA© Tool (modified; original in blue)
The conversation leads to documentation- not the other way around.
Question Response
Comfort •Intolerable
•Tolerable with discomfort
•Comfortably manageable
•Negligible pain
Change in Pain •Getting worse
•About the same
•Getting better
Pain Control •Inadequate pain control Inadequate pain control
•Partially effective Effective, just about right
•Fully effective Would like to reduce medication (why?)
Functioning •Can’t do anything because of pain
•Pain keeps me from doing most of what I need to do
•Can do most things, but pain gets in the way of some
•Can do everything I need to
Sleep •Awake with pain most of night
•Awake with occasional pain
•Normal Sleep
From, Donaldson & Chapman, 2013.
Change or Transformation?
Change is the “fixing” of past to future:
� Better, cheaper, faster, leaner, etc.
Transformation is the job of leaders:
� Building a vision
� Start with the future and
work back
� Help people fall in love with the future
10/26/2015
4
Transformation
The butterfly is NOT
a better, faster
caterpillar.
It is a NEW
system.
Building an Institutional Commitment
to Pain Management
Gordon DB, Dahl JL, Stevenson KK (1996) and (2000)
• A resource manual that provided a framework to
promote practice changes that would improve
quality of pain management for all patients.
Steps of Implementation
1. Define the scope and team
2. Identify and manage the risks
3. Breakdown the work
4. Schedule the work
5. Communicate
6. Measure progress
From, Verzuh (2008).
University of Minnesota Medical Center
– A River Runs Through It
1932 licensed beds
885 staffed beds
1. Defining the scope and team – Phase 1
Scope (Adult Inpatient)
• Medical Units
• Surgical Units
• Behavioral Units
• Obstetrics Units
• Acute Rehabilitation
• Transitional Care
• Emergency Departments
• Perioperative Services
Team
• Champion: Chief Nursing Executive
• Quality and Performance Improvement Consultants
• Data Analysts
• Electronic Health Record Consultant
• Nurse Managers
• Staff Nurse Leaders
• Nurse Educators
• Communications Department
1. Defining the scope and team – Phase 2
�Infusion Centers
�Clinics
�Procedural Areas
• Scope (Adult Outpatient)
10/26/2015
5
1. Defining the scope and team – Phase 3
�Process begins with validation of tool in pediatric
population
• Scope (Pediatrics)
2. Identify and manage the risks
Potential failures/risks
• Failure to gain cooperation
of nurses and physicians
• Concerns of researchers
using the numeric scale
• Failure to increase patient
satisfaction or improve pain
management
Managing Risks
• Buy-in from key leaders
• Contacted IRB to notify
researchers of change
• Weekly monitoring of
process with monthly
monitoring of outcomes
3 & 4. Breakdown and schedule the work
Aug ‘13 Sept Oct Nov Dec Jan ‘14 Feb Mar April May June July
Take to Leadership groups
Develop content of
presentations
Establish plan for data
collection
Build doc and reports to
support
Form House w ide Group and
unit based group
Engage Stakeholders
Assess current state of
practice, research (
Communicate/educate all
disciplines
Implement: Inpatient
Monitor, evaluate, tweak,
sustain
Implement: Outpatient
,
Month
Determine & Establish
Accountability desired
outcomes, Structure /roles
at all levels
5. Communicate
• Who
– Special interest groups: Nurse Managers/Directors, nursing staff, physician groups, APRNs, nursing practice committees, social workers, therapists, champions
• When
– Before, frequently throughout
• What
– Purpose, expected behaviors, expected outcomes, patient/family feedback, process and outcome measures
• How
– Via meetings, newsletters, intranet, patient stories, staff stories, e-mail
6. Measure progress
• Process measures:
– Weekly compliance report per unit
– Identification of individuals still using numeric
scale: can be coached and counseled
• Outcome measures:
– Monthly CAPA© outcomes
– Press Ganey© pain satisfaction scores
Objective 2: Summarize the outcomes of
University of Minnesota Health’s
implementation of CAPA©.
10/26/2015
6
Electronic Data AbstractionProcess Measures
CAPA © Compliance
Outcome Measures - CAPA©
6.41%
27.01%
22.67% 22.67%21.82%
18.96%
16.67%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
January February March April May June July
Effectiveness of Pain Control (by Month)
Outcome Measures - CAPA©
50.50%
51.48%50.95% 50.95%
51.23%50.75%
51.04%
44.00%
46.00%
48.00%
50.00%
52.00%
54.00%
56.00%
58.00%
60.00%
January February March April May June July
Degree of Comfort by Month
Outcome Measures – Press Ganey ©
• Overall Pain Management
– Staff Did Everything They Could to Help With Pain
– Pain Well Controlled
Press Ganey© - Overall Pain Management
(by month)
50
55
60
65
70
75
80
% Average 3 STD 2 STD
10/26/2015
7
Press Ganey© - Staff Did Everything to Control Pain
(by Month)
60
65
70
75
80
85
90
% Average 3 STD 2 STD -2 STDEV -3 STD
Press Ganey© Scores Pre and Post
CAPA Implementation by Quarter
Anecdotes
Patient perspective: “Makes me feel like the nurses care more about my pain.”
Nurses perspective:
• “It makes sense.”
• Many had been frustrated by numeric scale and liked the change. “I hated that 0-10 scale.”
Nurse Survey1 med-surg unit (N=21, 67% return)
80% satisfied or very satisfied with implementation
80% felt communication with patients improved with CAPA ©
71% satisfied with rationale for change
66% preferred CAPA© over NRS
47% believe patients have somewhat better pain
management with CAPA ©
Thanks to Emily Drobinski, Carrie Hallstrom, Kelly Pavlicek, Mary Sylvestre,
Heather White , Clare Zielinski: Unit 8A, UMMC
Objective 3
• Describe the lessons learned from
implementing a complex and culture-changing
project.
Learnings
• Numeric scale embedded in many different
places in EHR.
• Pain assessment by many different people
– Students, faculty, therapists, technicians, etc.
• Some staff are not skilled at “talking with”
patients; this presented a challenge.
• Some people resist change!
• Staff can be the biggest champions!
10/26/2015
8
Unexpected Occurrences Information about the CAPA© tool
• Tool not validated according to standards of psychometrics.
• Study by Drew, Hagstrom & O’Connor-Von (unpublished) found no correlation between numerical scores and concurrent CAPA comfort domain. N=30, repeated measures
Found that can’t compare quantitative data to qualitative data.
• Donaldson (2014) recommends nonparametric approach in research design
Additional Learnings
• Staff need to recognize this as culture change
versus a “project”
• Glitches happen in spite of best planning
• Ripple effects of change occur
• Barriers along the way: people, processes,
tools
• Facilitators: people, processes, and tools
Implications for Outpatient Settings
• Pain screening question in clinics = numeric
intensity score gathered by non-professional
– Didn’t cue professional about patient’s pain status
or concerns (documentation not readily visible)
– Didn’t meet the intent of TJC standard to assess
patient’s pain in outpatient setting
Recommendations
for Outpatient Settings
• Delete numeric pain scale from intake data.
• Ask screening question: “Do you have pain that needs to be addressed at this appointment?”
• Answer flows to Vital Signs flow sheet that is reviewed by RN and provider
• CAPA available on flow sheet for charting pain assessment
• Dot phrase available for easy charting in narrative note if preferred by provider.
Recommendations in Process
• “Make it hard to do the wrong thing, and easy to do the right thing.” Joanne Disch, PhD, RN
• Educate via presentations, electronic learning, written materials, interpersonal meetings. Repeat, repeat again….
• Utilize electronic medical record to match work flow
10/26/2015
9
Recommendations
• Speak to fears and concerns:
– Fear of making an “assessment”: some nurses are
more comfortable with patient’s statement of a
number than trying to interpret interaction
– MDs fear that they won’t know how to respond
when nurse calls with CAPA information
• Engage executive leadership as necessary
A Tale of Two Emergency Departments
West Bank ED 2nd Quarter
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3/24 3/31 4/7 4/14 4/21 4/28 5/5 5/12 5/19 5/26 6/2 6/9 6/16 6/23
3/24 3/31 4/7 4/14 4/21 4/28 5/5 5/12 5/19 5/26 6/2 6/9 6/16 6/23
Both CAPA and Numeric 12% 7% 9% 7% 7% 5% 5% 2% 2% 2% 3% 1% 1% 0%
CAPA Only 84% 90% 87% 91% 90% 94% 94% 97% 98% 97% 96% 99% 98% 100%
Numeric Only 4% 3% 3% 2% 3% 1% 2% 0% 0% 2% 1% 0% 1% 0%
Both CAPA and Numeric
CAPA Only
Numeric Only
East Bank ED 2nd Quarter
VP Letter to Staff
Summary
• Pain assessment is not merely the subjective
statement of the patient, no more than it is the
sole objective decision of the clinician.
• Rather, pain assessment is the intersubjective
exchange of meaning between the patient and
clinician.
• It is a process, which is ongoing and dependent
on both the internal and external factors inherent
to both the parties and their environment.
Summary
• CAPA© is an expanded way to assess pain using a transactional conversation between patient and clinician.
• Findings: Changing from the numeric scale to the CAPA© tool is a cultural change for staff and patients.
• Next steps at M Health include:
– Expansion to most care settings within hospital system.
– Validation of tool in adolescents
10/26/2015
10
The Impact
“Nobody makes a greater
mistake than he who
did nothing because he
could do only a little.”
Edmund Burke
The Power of Many Drops
Questions ? References
Donaldson, G., & Chapman, C.R. (2013). Pain management is more
than just a number. University of Utah Health/Department of
Anesthesiology. Salt Lake City, Utah: Department of Anesthesiology.
Schiavenato, M., & Craig, K.D. (2010). Pain assessment as a social
transaction: Beyond the gold standard. The Clinical Journal of Pain,
26(8), 667-676.
University of Utah Health Care. (n.d.). Giving patients a voice, not a
number. Retrieved from:
http://healthcare.utah.edu/nursinginnovation/10ideas/two.php
Verzuh, E. (2008). Fast forward MBA in project management (3rd ed.).
Hoboken, NJ: John Wiley & Sons, Inc.