Matching Interventions to Barriers in Pain Management Ruth Cornish Program Manager

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

What we do What we know

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

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

Background

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

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

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

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

Where to start?

Matching interventions to barriers

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

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

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

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

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

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

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

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

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

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

Matching interventions to barriers

Begins with a sound analysis of barriers