1. MOPAT A new tool for assessing pain in hospice patients who can’t self-report
Presenters:
Deborah Bortle, MS, BSN, CHPN
Joan K. Harrold, MD, MPH, FACP, FAAHPM

2. Pain Assessment in Hospice Patients
Patients able to self-report
Patients not able to self-report
How do we it?
What are the challenges?
What do we need?

3. MOPAT: Multidimensional Objective Pain Assessment Tool
University of Maryland School of Nursing
Preliminary work (McGuire & Reifsnyder, 2004) suggested that at least 2 dimensions of acute pain—behavioral and physiologic—could be assessed in non-communicative palliative care patients.
Goal: to validate the MOPAT and demonstrate its feasibility in a spectrum of palliative care settings when used by both nurses and informal caregivers to assess acute pain in non-communicative patients.

4. MOPAT Hospice of Lancaster County ADC 450-500 12 bed IPU, mainly GIP
Second IPU opened, 16 beds, mainly GIP
Research MS/BSN 0.5 FTE
On-site IS manager to enable EMR data collection

5. MOPAT in Hospice Remove blood pressure measurements
Not routinely performed, especially at EOL
Could limit future clinical utility
Staff other than nurses
Other caregivers

6. Study Design Eligible IPU patients suspected of having pain
Simultaneous MOPAT assessments by Study RN and Staff nurse (RN or LPN)
1 primary Study RN with 1 back-up
Reassessment following intervention
Timing based on intervention used
Staff MOPAT results documented in EMR
Study MOPAT results not included in patient record
Serial values were used clinically even if not recorded for the study

7. Inclusions/Exclusions
Adults with evidence of pain and not able to self-report
Exclusions
Non-responsive
Pediatric < 18 years old
RAST < 5
Any diagnosis of dementia

8. MOPAT

9. Recruitment and Education
Hospice decided MOPAT to be used in IPU for all patients
Regardless of patient enrollment in study
Every IPU nurse trained on MOPAT
MOPAT Incorporated into IPU EMR
UMd created a video of case scenarios
Revised for hospice environment
Unit Director volunteered to be patient in video
Researchers and IPU leaders performed consensus ratings prior to use for training

10. Training Trained staff over 3 months
39 RNs and 22 LPNs agreed to participate in study
1 RN and 1 LPN declined, but still utilized MOPAT
Same instructor for everyone
Out of the IPU for training
Associated color: PURPLE magnets
Included snacks
Thank you gift: MOPAT clipboard
Feedback via fliers when general issues identified

11. Clinical Utility Assessment
Completed monthly by nurses who volunteered to participate in this arm of study
No additional incentives
Did nurses like the tool?
Would they use the tool?

12. Patient Enrollment Project began March 7, 2009
Nurses had 3-5 months to use before enrollment patient
50 patients enrolled by December 11, 2009
Last patient enrolled November 23, 2010
21 month enrollment period for 100 patients

13. Challenges to Enrollment
IPU transfers 5pm-8am and on Saturdays
Opening of new IPU 7 miles away
Reasons not enrolled:
50% diagnoses included dementia
22% died prior to study assessment
20% died before re-assessment
2% study nurse not available
2% RAST < 5

14. Results: Nurses using MOPAT

15. Results: Return Rate CUQ’s (%)

16. Results of MOPAT in Hospice
Reliability
Agreement between Study nurse and Staff Nurse raters was significant at p<.001, with moderate-substantial agreement on most indicators.
Validity
Validity was evidenced by statistically significant (p<.001) reductions in behavioral, physiologic, and total MOPAT scores following pain interventions.

17. Clinical Utility Questionnaire

18. Results: Utility Guided pain assessment Assisted in communication
Helped determine if pain present
Helped determine intervention needed
63.9%
61.1%
61.6%
60.3%

19. Results: Ease of Use Reasonable time to complete 63.8%
Easy to use %
Feasible for regular use %
Easy to understand %

21. Adjustments to MOPAT Eliminate diaphoresis on MOPAT tool
Added no value
Shortened time to complete

22. Home Hospice Roll-out Roll out to admission team first
Tried to get their feedback before HH roll out
Easier to use than they expected
Liked an objective tool
Didn’t like having another form to complete
Recognized need for standardized tool for patients with dementia who cannot self-report
Dementia in IPU accounted for 50% of those excluded from MOPAT study
PAINAD added to EMR prior to HH roll-out

23. Home Hospice Training
Power point presentation in IDT plus make-up sessions
All IDT members included
Written case scenarios for selection of appropriate tool
MOPAT and PAINAD tools in handouts
Flow chart on how to document your pain assessment
Self report—if unable, choose either…
PAINAD
MOPAT

24. Issues in Home Hospice Nurses using assessment tools interchangeably
Even for same patient
More than expected from fluctuations in clinical status
Using self-report while awake and MOPAT while asleep
Using MOPAT and PAINAD for same patient
Nurses only using a tool after they determine patient has pain
Need to use to help determine if a patient has pain
Allows next clinician to compare pain levels using same variables
Communication, not clinical accuracy

25. Issues in Home Hospice Definition of dementia
34.8% with dementia had a MOPAT completed
Emphasize self-report first!
What constitutes a diagnosis of dementia?
Problem or dx list? Family report? Clinical notes?
Timing of focus on NQF #0209
Comfort in 48 hours
Self-report only
Diminished focus on assessment of patients who cannot self-report

26. Lessons Learned Roll-out with fanfare
Need excitement to make an impression
Don’t roll-out with too many other new things
Use the video scenarios in all training
Ask for feedback
Can use the CUQ, but not every month!
Deliver rapid feedback to teams on MOPAT use
Develop organizational policy regarding dementia diagnosis

27. Future Directions Use CUQ’s to get nursing feedback in Home Hospice
Beginning January 2013
Explore use by other caregivers
Nursing home clinicians
Caregivers at home
CUQ: MOPAT could be used by informal caregivers
1.9% disagree
39.8% undecided
58.2% agree

28. Appreciation to Our Colleagues
Deborah McGuire, PhD, RN, FAAN
Principal investigator
Karen Kaiser, PhD, RN-BC, AOCN
Karen Soeken, PhD
JoAnne Reifsnyder, PhD, ACHPN