Can Specific Physician Orders about Pain Medications Improve Pain Management in LTC? Ralf Habermann, MD, CMD (Co-PI) Sumi Misra, MD, MPH, CMD (PI) Tracy Porchak, Project Coordinator Jamie Spicer, GNP Vanderbilt University

Faculty Disclosures: Dr. Habermann and Dr. Misra have disclosed that they have no relevant financial relationships.

Acknowledgements: Vanderbilt University, School of Medicine, Center for Quality Aging John F. Schnelle, PhD Sandra F. Simmons, PhD AMDA/Pfizer Quality Improvement Award

Background Pain is prevalent in LTC Pain assessment is required as a 5th vital sign Pain is often undetected and untreated, even though most (>90%) LTC residents are able to reliably answer pain questions LTC Residents are often not given the choice of PRN pain medication References: 1. Chu L. et.al. JAGS 2004, 52:2057-2061. 2. Cadogan M et.al. J Geron:Med Sci, 2004, 59:281-285.

Background Specific physician orders changed nursing home staff behavior for supplement delivery - Between meals instead of w/ meals May be able to impact other aspects of care References: Simmons et.al. 2006 JAGS 54(9):1372-1376. Whiteman et.al. JNHA (in press).

Purpose To determine if specific physician orders about pain medications improve pain management in LTC How can Physicians improve daily care Quality

New Physician Order Ask resident during medication pass: “Do you have pain now?” If resident responds “yes”, ask: “Would you like some medication for it?” If resident responds “yes”, offer choice of PRN pain medication (if necessary in addition to scheduled pain medication) Note: Order was implemented for all med pass delivery periods but night pass was not observed by research staff

Methods One nursing home Study Inclusion Criteria Able to self consent (as per IRB) Order for Pain Medication (Scheduled/PRN) 53/104 eligible (51% Consent Rate)

Demographics (n=53) Average Age: 83 years (+ 9) 68% Female 70% Caucasian Average Length of Stay: 1.9 years (+ 3.0) 72% Long-Term Care (remainder sub-acute) Chart Order for Pain Medications 63% Order for Scheduled 96% Order for PRN

Most Common Pain-Related Diagnoses Arthritis: 49% Stroke: 36% Osteoporosis: 34% Cancer: 28% Other Common Diagnoses: Depression: 51% Dementia: 36%

Methods: Data Collection 2 Days (morning, afternoon, evening) med pass Total of 6 observations per person baseline/post Same Days as Observation: - Resident Interviews about pain - Chart Review (pain medications given)

Methods: Timeline Baseline – 2 observation days week one New Physician Order immediately after baseline Post – 2 observation days - Day 1 immediately after order - Day 2 one week after order Follow-up (in progress) one month after order d/c’d

Results: Observations Medication Passes: 2 days pp (morning, afternoon, evening) Baseline Post Did nurse ask if resident had pain? 20% 67%* Did resident say they had pain? 12% 23%* *p<0.05 Note: Numbers reflect percent of observations that question was asked or response was “yes”.

Results: Observations Medication Passes: 2 days pp (morning, afternoon, evening) Baseline Post If “yes” to pain, did nurse ask if resident wanted medication? 12% 37%* Did resident want pain medication? 11% 20%* *p<0.05 Note: Numbers reflect percent of observations that question was asked or response was “yes”.

Results: Chart Review Pain Medication Delivery Per Resident / 2-days (6 passes) Baseline Post Average Total PRN given per resident 0.53 0.84* Percent of residents with 1 or more PRNs given 37% 51%* Percent of residents who wanted & received PRNs 93% (13/14) 90% (18/20) p

Results: Resident Interview Interview Question Baseline Post Do you tell the nurse about your pain? 69% 77% Does the nursing staff ask you about your pain? 58% 80%* Do you prefer to take medication when you feel pain? 72% *p<0.05 Note: Numbers reflect percent of “yes” responses.

Results: Observation Mode Range Average Total Time 1min Time nurse spent with each resident per medication pass Mode Range Minutes: Seconds Average Total Time 1min < 1 to 10 min Nurse asked if resident had pain Nurse asked if resident had pain & offered pain med 2min < 1 to 12 min *Note: Total time spent with resident includes care activities beyond med pass

Results Summary Nurses asked residents questions about pain during medication passes more frequently following the new order. Residents expressed pain more frequently in response to nurses’ questions. Residents asked for pain medication more frequently in response to nurses’ questions.

Results Summary It required one extra minute per resident/pass to ask questions and provide medication. Residents’ noticed the difference in nurse behavior. Most residents expressed a stable preference to take medication for pain. The number of PRN pain meds increased

Implications Specificity of physician orders may improve care in other areas Trial of toileting assistance for incontinence Walking assistance to/from dining room Offering residents choice during daily care CHF management i.e. diuretic dose depending on daily weight

Barriers to Improvement Inadequate staffing to provide care consistent with order Staff Resistance Variance in nurse pain assessment and treatment - Limits care to specific time of day or protocol Survey Compliance Risk - Documentation will show care was not provided as ordered

Study Limitations Only one nursing home site. Short time frame for evaluation (< 1 month) Residents most at risk for undetected and untreated pain (more cognitively impaired) were not included even though these residents are able to respond to nurse questions ( due to IRB concerns)

Future Development of specific facility wide protocol order set Inclusion of all residents in this program Reduction of potential for nurses bias regarding pain medication

Conclusion YES Physician orders have an impact and can change institutional behavior