1. 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

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

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

4. 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:
2. Cadogan M et.al. J Geron:Med Sci, 2004, 59:

5. 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 JAGS 54(9):
Whiteman et.al. JNHA (in press).

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

7. 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

8. 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)

9. 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

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

11. 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)

12. 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

13. 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”.

14. 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”.

15. 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

16. 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.

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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)

23. 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

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