1. Matching Interventions to Barriers in Pain Management Ruth Cornish Program Manager

2. National Institute of Clinical Studies Role: To improve health care by helping close important gaps between best available evidence and current clinical practice

3. What we do What we know

4. Acknowledgements Prof. Sanchia Aranda NICS advisors Deb Gordon & June Dahl (Wisconsin pain group) Pilot hospital teams

5. Pilot hospitals Royal Brisbane Westmead Newcastle Mater Peter Mac Flinders Royal Adelaide Royal Perth Charles Gairdner

6. Background www.nicsl.com.au

7. Aims 1.To improve the identification of patients with pain 2.To improve the day-to-day management of pain for patients with cancer 3.To integrate effective cancer pain management into the core business of hospitals

8. Barriers - Institutional Lack of institutional commitment Poor visibility of the problem Professional territorial issues Unclear lines of responsibility Lack of practical tools & policies

9. Barriers – Clinicians Attitudes & beliefs of staff No routine pain assessment Under-estimation of patients’ pain Analgesia misconceptions Prescribing & administration inconsistencies Inadequate knowledge and education

10. Barriers – Patients Inevitability of pain Stoicism Analgesia fears & misconceptions Being a “good” patient Distracting from treatment Trade-offs: analgesics & side effects

11. Where to start?

12. Matching interventions to barriers

13. Lack of knowledge –Educational courses –Evidence based guidelines –Decision aids Beliefs/Attitudes –Peer influence –Opinion leaders Lack of motivation –Incentives / sanctions Perception-reality mismatch –Audit & feedback –Reminders Systems of care –Process redesign Generic Principle

14. Institutional Lack of institutional commitment –Executive champions –Peer hospitals? Poor visibility of the problem –Audit & feedback to executive –We have a problem!

15. Institutional Professional territorial issues –get everyone involved –multiple champions Departments Pain Palliative care Medical/Surgical Quality/safety Disciplines Nursing Medicine Pharmacy Quality/safety eg.

17. Clinical Inadequate knowledge, education –needs analyses useful –don’t expect attendance at special meetings –use existing meetings opportunistically –include in orientation, rounds, intranet –nursing competency standards

18. Clinical Attitudes and beliefs –Opinion leaders –Clinical champions –Peers

19. Clinical No routine assessment –documented pain scores on vital sign chart –reminders –audit & feedback essential

20. Clinical Prescribing inconsistencies –guidelines and decision aids at point of prescribing –equi-analgesia cards –standardised prescribing

21. Patient Inevitability of pain; stoicism; being a "good" patient –"your pain is important to us" –organisation mission statement –hospital admission/discharge information includes pain management –ward posters

22. Patient Distracting from treatment –"your pain is important to us" –involve patient in their own pain management –prompts to discussion

23. Patient Analgesia fears, misconceptions (particularly addiction) –starting morphine is a "threatening procedure" for cancer patients –information for patients & families

24. Matching interventions to barriers

25. Begins with a sound analysis of barriers