Rapid improvement in pain management: the Veterans Health Administration and the institute for healthcare improvement collaborative

One-year follow-up after a collaborative breakthrough series on reducing falls and fall-related injuries

BACKGROUND

Multisite facilitated quality improvement (QI) projects, called collaborative Breakthrough Series (BTS), have been shown to improve care, but it is also important to evaluate the lasting effects and spread of changes of BTSs. A project focused on fall and injury-related prevention started in Spring 2001; after the project's end, support was provided through e-mail and periodic conference calls.

METHODS

One year after project completion, team contacts were interviewed to determine if they had maintained gains or made further improvements.

RESULTS

For the 34 (of 37 teams) interviewed, 82.4% reported they had stayed together as a team; 97.1%, that they continued to collect data; 93.9%, that they had maintained gains; 82.4%, that they had spread changes to new locations; and 85.3%, that they had begun to work on new topics. High team performance at one year correlated with first-meeting team characteristics Leadership Support (r = .456, p = .019) and Prior Experience with Quality Improvement and Teamwork (r = .393, p = .047) and with follow-up team characteristics Leadership Support (r = .614, p < .001), Teamwork Skills (r = .377, p = .033), and Skills Gained from the Project (r = .410, p = .020).

CONCLUSIONS

Leadership support, experience with quality improvement and teamwork, teamwork skills, and skills gained from the project were correlated with teams' abilities to achieve and maintain success.

Predictors of upper extremity discomfort: a longitudinal study of industrial and clerical workers

Upper extremity discomfort associated with work activity is common with a prevalence of over 50% in many settings. This study followed a cohort of 501 active workers for an average of 5.4 years. Cases were defined as workers who were asymptomatic or had a low discomfort score of 1 or 2 at baseline testing and went on to report a discomfort score of 4 or above on a 10-point visual analog scale. This change is considered clinically significant. Controls had a low baseline discomfort score and continued to have a low discomfort rating throughout the study. The risk factors found to have the highest predictive value for identifying a person who is likely to develop a significant upper extremity discomfort rating included age over 40, a BMI over 28, a complaint of baseline discomfort, the severity of the baseline discomfort rating and a job that had a high hand activity level (based upon hand repetition and force). The risk profile identified both ergonomic and personal health factors as risks and both factors may be amenable to prevention strategies.

Pain intensity assessment by bedside nurses and palliative care consultants: a retrospective study

OBJECTIVE

To evaluate the specificity, sensitivity, and accuracy of pain intensity assessments (0-10) conducted by registered nurses (RN) and clinical nurse assistants (CAN) as compared to those conducted by the palliative care consultant (PCC).

PATIENTS AND METHODS

We performed a retrospective review of charts of patients who had received palliative care consult between April 2002 and August 2002. Data on patient demographic, date of palliative care consult, and date and intensity of pain assessment were collected. A numerical rating scale from 0 (no pain) to 10 (worst pain) was used to assess pain intensity. The data were included for analysis if the pain intensity assessment was performed during the same shift by all three care providers (RN, CNA, and PCC).

RESULTS

Forty-one charts were found to include a complete pain assessment performed by the RN, CNA, and PCC. The agreement of pain intensity between the PCC and both the RN and CNA was poor. For a diagnosis of moderate-to-severe pain, the RN's intensity assessment had a specificity of 90% but a sensitivity of 45%, and the CNA's intensity assessment had a specificity of 100% but a sensitivity of only 30%. The Spearman correlation coefficient between the intensity assessments performed by the PCC and the RN was 0.56 (p=0.00) and between those by the PCC and the CNA 0.22 (p=0.15).

CONCLUSION

Lack of agreement between pain intensity assessments performed by the PCC and bedside nurse suggests possible inconsistencies in the way the assessments were performed. Better education on how to perform standard pain intensity assessment is needed.

Pain and fatigue in community-dwelling adults

BACKGROUND

Pain and fatigue are common debilitating symptoms reported by both patient and community-dwelling populations. However, population-based studies typically focus on psychosocial variables as correlates of fatigue, with little effort toward assessing pain as a risk factor. This study examines the specific relationship between pain and fatigue and the importance of mood and sleep as covariates of fatigue in a community-dwelling sample of adults. We also assessed the prevalence of mild, moderate, and severe fatigue for this sample.

METHODS

Data were collected using self-administered questionnaires assessing demographic characteristics and symptoms, including pain, fatigue, mood, and sleep disturbance, in a sample (N=274) of community-dwelling adults.

RESULTS

Regression analyses showed pain, mood, and sleep as significantly associated with fatigue, with pain being the most highly correlated. However, while pain accounted for the largest proportion of the variability in fatigue, mood modified the relationship between pain and fatigue. We also found that 9% of the sample reported no fatigue, 41% reported mild fatigue, 42% reported moderate fatigue, and 8% reported severe fatigue.

CONCLUSIONS

Our findings provide empirical support of the importance of assessing pain as an important risk factor of fatigue and examining mood as a covariate in population-based studies of fatigue.