Transcript How Important to you is pain control for wound dressing changes?

Alex Fay, Michael Frederick, Brent Sugimoto, Jed Wolpaw
PISCES Quality Improvement Project
UCSF School of Medicine
Class of 2010
Can we do something to improve pain
management during dressing changes
in the hospital?
Can we change systems of care to
facilitate premedication of surgical
patients prior to wound dressing
changes?
 Is
solving the problem beneficial?
• Is Pain Control Good?
 Who
does the protocol benefit?
 Who are the stakeholders?
• Do they support the intervention?
• What is the impact on the individual stakeholders?
 What
is the plan?
• Why this intervention and not others?
• Is the plan feasible?
 Implementation
 Future
& Evaluation
directions. . .
YES!
Expectation
Satisfaction
- Satisfaction survey11
- Pain Scale12,14
- Improved outcomes15,16,17,18
11Carrougher
- Personal
experience/Anxiety8
- Virtual Reality
Relaxation1,9
Pain Control
- Acetaminophen, NSAIDS, Opioids
- PO, IV6, intranasal4, PCA3, patch2
- Topical/Dressing5,7,10
- Alternative therapies13
et al (2003); 16Perkins et al (2000)

The patient!
 Others
 Doctors, Nurses & Health Staff
 The Medical Center
Nurse
Family
?
Patient
PainControlled
Dressing
Change
Resident
Surgeon
?
Patient
?
Family
Policy
Change
Surgeon
Nurse
Resident
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
NUMBER OF INTERVIEWS
 How
important to you is pain control for
wound dressing changes
 (1) Not Very
(10) Very Important
 Is
pain management during dressing
changes a problem? Please explain.
 How frequently is pain management
during wound dressing changes a
problem?
 (1) Almost Never
(10) Almost Always
 What
do you currently do to prevent pain
during dressing changes?
 How
do you evaluate when measures are
or are not needed for pain control during
dressing changes, if ever?
 What
are other options for pain control
with dressing change?
 What
is your role in the process?
 Who
are other people you can identify,
who affect this process?
 What
obstacles do you encounter in
preventing pain during dressing
changes?



What barriers can you identify to its implementation?
Please identify anyone—from patients, to health staff, to
administrators—who would be concerned about the
implementation of this new protocol.
Imagine UCSF began requiring adequate pain control
administration 15 minutes prior to dressing changes.
Please rate the feasibility of this new protocol in your
practice
(1) Impossible
to Implement
Implemented
(10) Easily
How Important to you is pain control for wound dressing
changes? (1 = Not important; 10 = Very important)
 Surgeon (4): 8.875
 Resident (4): 8.5
 Nurse (5): 10
 Patient (5): 9
How frequently is pain management during dressing changes
a problem? (1 = Almost Never; 10 = Almost Always)
 Surgeon (4): 4
 Resident (4): 4.5
 Nurse (5): 4.5
 Patient (5): 4.2
Not a problem when:
 Patient unconscious, intubated, epidural
 Adequate pain meds are given
 Patient tolerates pain (patient-to-patient variability)
CURRENT STRATEGIES FOR
PAIN PREVENTION
• Pain medications, PCA, epidural
• Gentle dressing removal
• Counseling, deep breathing, distraction,
anxiety reduction
• Call nurse 30 minutes ahead
OTHER OPTIONS FOR PAIN CONTROL
•
Conscious sedation, call pain team to bedside,
take patient to OR
•
Relaxation techniques, counseling, anxiolytics
•
Better planning with team
•
Involve patient in the process
ROLES IN DRESSING PAIN MANAGEMENT
 Role of Surgeons/Residents:
Advocate for patient, prevent oversedation
Resident: change dressing, order meds, contact ICU/pain
teams
 Role of Nurses:
Evaluate wound, change sometimes, consult
Initiate conversation about optimal pain management
 Others:
RT, Anesthesia, Sedation Nurse, Wound Care Specialist
Students
Family
FEASIBILITY OF PAIN CONTROL PROTOCOL
“Imagine UCSF began requiring adequate pain control
administration 15 minutes prior to dressing changes.
Please rate the feasibility of this new protocol in your
practice.”
(1)Impossible
(10) Easily
to Implement
Implemented
•
•
•
•
Surgeon (n = 4): 5
Resident (n = 4): 6.5
Nurse (n = 5): 6.25
Patient (n = 5): 5.75
PERCEIVED BARRIERS TO IMPLEMENTATION
 Logistics/timing
 Senior resident has to see wound
 Not necessary for all patients
 Assessing pain
 Dosing meds appropriately
SUMMARY OF FINDINGS
 All Stakeholders See Pain Control as Important
 Pain During Dressing Changes is Inadequately
Controlled in Some Patients
 All Stakeholders Have Doubts About Feasibility of
Mandated Pain Protocol
 Reasons:
 Logistics (Time, Communication)
 Each Patient is Different/How to Assess Individually
 Not Necessary in All Cases
SUMMARY OF FINDINGS
 Strategies Already Employed
 Call Ahead to Nurse to Pre-Medicate Patient
 Epidural Anesthesia
 Take Patient to OR
 Relaxation Techniques, Anxiolytics
 Intervention
Focus on Improving Logistics, Not Education or New
Technology
C.A.R.E.
• Call RN in advance
• Ask the nurse to give pain medication
• Remove Dressing
• Evaluate Pain
 OR
Nurses-Have charge nurses review CARE
at each pre-shift meeting
 Room/Chart Flag: “Dressing Change
Precautions” (like contact precautions)

If Patient tells RN, Resident, or Attending that she/he is
having pain with dressing changes, room/chart flag is
placed, making pain control mandatory 15 minutes
before dressing changes.
Re-administer the following questions
from survey:




Is pain management during dressing changes
a problem?
How frequently is it a problem?
Improvement in scores over time will
indicate success of intervention
 Empowering
personnel
midlevel
 NPs or PAs to do dressing changes,
possibly with photos or video for
attending and residents to review
 Anesthesia
 Incorporate post-op pain control
planning into anesthesia choices
 Epidural catheters allow for
excellent pain control post
operatively
 Pain control is important to MDs, RNs, and patients, but
inadequately managed in some patients
 Current systems barriers impact consistent pain
control
 There is no preexisting mechanism for ensuring pain
control during dressing changes
 Using preexisting models and stakeholder
consultation, we designed an implementation plan for
a three-part intervention
 We believe this intervention could improve patient
satisfaction and outcomes.
 Drs. Tong
and McGrath
 The Nurses, Residents and Attendings
who willingly took our surveys
 The patients who we are privileged to
work with and who inspired our project
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2
3
4
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