Nursing Knowledge of Opioid Use for Symptom Management at the End of Life Holly Fulmer and Jordana Meyerson Dana Farber Cancer Institute and Brigham and Women’s Hospital February 5, 2016 Keywords: Opioid, nursing, pain, dyspnea, education, terminally ill, survey, case study

Problem Statement Nursing staff have varying degrees of knowledge surrounding the use of opioids for symptom control at the end of life resulting in both under and overuse of these medications. Misunderstanding the theory of opioid use for palliating symptoms is well-documented and might impact nurses’ ability to adequately and safely control patients’ symptoms at end of life.

Baseline Data

Baseline Data

Baseline Data

Prioritized List of Changes (Priority/Pay-Off Matrix) High Low Easy Difficult Identify gaps in nursing knowledge about opioid medications, their uses, and adverse effects of these medications. Ask nurses to take a survey, watch a brief video containing teaching points about opioids, and take a follow up survey. Assess nursing attitudes toward opioid medications. Impact Post educational materials in common areas of floors being administered the survey. Arrange an in-person education session (few people would be able to attend an isolated session). Ease of Implementation 6 6

PDSA Plan (Tests of Change) Date of PDSA cycle Description of intervention Results Action steps 1/7/16-1/15/16 Assess nursing knowledge of opioid medications via a survey. Variable knowledge on opioid use and adverse effects providing guidance for intervention. Create narrated presentation with teaching points about opioids. Narration reviewed for comprehension. 1/25/16-2/3/16 Post-presentation survey administered to assess whether nurses had new knowledge. Improvement in knowledge scores, more pronounced for objective questions. Tailor survey to include more objective questions. Set up area for viewing video with volume.

Materials Developed https://www.youtube.com/watch?v=TtHPFR34jWM&feature=youtu.be

Change Data Myoclonus1 10  53 53  47 32  0 5  0 Hyperalgesia2 Strongly agree (%) Agree (%) Disagree (%) Strongly disagree (%) Myoclonus1 10  53 53  47 32  0 5  0 Hyperalgesia2 0 40 11  60 74  0 16  0 Delirium3 0  0 22  7 61  53 17  40 Double dose 0  20 26  7 63  73 11  0 Sedation4 0  33 32  53 58  13 Morphine 37  27 53  27 11  47 Infusion 37  20 58  60 5  20 Kidney/liver 11  7 53  23 37  47 Dosage 0  7 26  53 63  33 Opioid medications can cause spasm of the muscles (myoclonus). Opioid medications can cause increased pain. If a patient is delirious, opioid medications should be stopped. To prevent opioid-induced respiratory depression, nurse monitoring of sedation level is more important than monitoring respiratory rate.

Selected Positive Results

Conclusions Baseline data supported the problem statement. Nurses had varying degrees of opioid knowledge. Overall, scores improved on various measures of opioid knowledge, meeting our AIM statement. Objective questions resulted in greater improvement in knowledge.

Next Steps/Plan for Sustainability Things to consider Additional tests of change We will generate more objective questions. System based changes We will arrange a viewing of our video in a room with sound. Measurement & reporting We would measure and collect data in the same manner. People We will provide incentives to ensure continued participation. We will advertise prior to initiating the project.