Quality Improvement Initiative to Improve Postoperative Pain with a Clinical Pathway and Nursing Education Program

The Development and Implementation of an Evidence-Based Tumescent Liposuction Protocol, Online Educational Course for Perioperative Staff, and Discharge Instructions: A Quality Improvement Project

PURPOSE

The purpose of this quality improvement project was to improve perioperative management of patients undergoing tumescent liposuction (TL) through the development and implementation of a perioperative evidence-based protocol, educational course for perioperative staff, and patient discharge instructions.

DESIGN

The TL protocol was validated using the modified Delphi process. The educational course and discharge instructions used a pre and postimplementation design.

METHODS

An evidence-based protocol, an educational course for perioperative staff, and readable discharge instructions for patients undergoing TL were developed in accordance with best practice guidelines. The protocol was validated by subject matter experts at the facility and submitted for adoption. The evidence-based educational course was implemented, and the effectiveness of the course was evaluated for improving providers' knowledge and self-confidence. The evidence-based discharge instructions were implemented and evaluated for patient satisfaction and readability.

FINDINGS

Three items were removed from the protocol, 2 items were modified, and 25 items were accepted with no change from modified Delphi analysis. Provider knowledge scores improved from 85.7% ± 16.18 to 97.1% ± 4.88; however, this was not statistically significant (P = .066). There was a trend toward improved confidence scores (P = .180). Overall patient satisfaction scores slightly improved postimplementation; results were not statistically significant (P > .05).

CONCLUSIONS

All three phases of perioperative care in patients receiving TL were evaluated, reflecting best practice guidelines and successful adoption. There was no statistically significant improvement in provider knowledge, provider self-confidence, or patient satisfaction. A small sample size was a significant limiting factor.

Post-operative pain management by nurses in an intensive care unit: a best practice implementation project

INTRODUCTION

Post-operative pain is the most prevalent type of acute pain. Nurses are the health care professionals who most frequently assess pain, as well as evaluating the patient's response to pain management treatment and monitoring for the occurrence of adverse events. Thus, to improve outcomes and quality of care, the interventions used by nurses should be based on best practices.

OBJECTIVES

The aim of this project was to implement best practices in post-operative pain management in an intensive care unit.

METHODS

This evidence implementation project was conducted in a hospital for the surgical treatment of orthopedic diseases and trauma. The project followed the JBI evidence implementation framework. The project used JBI PACES software as well as JBI's Getting Research into Practice (GRiP) audit and feedback tools to develop eight audit criteria for the baseline and follow-up audits.

RESULTS

The baseline audit showed that criteria 3 and 6 had low compliance, with few patients having documented plans and goals, and receiving multimodal analgesia in the ICU, respectively. Criteria 7 and 8, which assessed the use of opioids and follow-up by a pain specialist, revealed compliance of 60% and 50%, respectively. Criterion 3 improved from 0% to 20%. Criteria 6, 7, and 8 also improved, rising to 30%, 22.8%, and 50%, respectively.

CONCLUSION

The project improved compliance with best practices in post-operative pain management. Further studies are needed to ensure the project's long-term sustainability.

[Application of Precision Nursing Based on Multidisciplinary Collaboration Model in Older Patients Undergoing Thoracoscopic Surgery for Lung Cancer]

Objective

To examine the application effect of precision nursing strategies based on multidisciplinary collaboration model in older patients undergoing thoracoscopic surgery for lung cancer.

Methods

A total of 100 patients who were admitted to our hospital for thoracoscopic surgery for lung cancer between July 2022 and March 2023 were prospectively enrolled for the study. They were assigned, with a random number table, to two groups, a control group receiving routine nursing care and an experimental group receiving nursing care based on multidisciplinary collaborative precision nursing strategies. Their lung function, anxiety and depression scores, and quality of life were assessed at three points of time, including upon admission, one week after surgery, and one month after surgery, and comparison was made between the two groups.

Results

There were significant differences in forced expiratory volume in one second (FEV1) at the three time points ( F=156.787, P<0.001) and the ratio of FEV1 to forced vital capacity (FVC) (FEV1/FVC%) at the three time points ( F=25.587, P<0.001) between two groups. There were significant difference between the findings for FEV1, FEV1/FVC%, FVC, and maximum voluntary ventilation (MVV) indexes at 1 week and those at 1 month after surgery in the experimental group ( P<0.05). After the surgery, the pulmonary function of the experimental group was better than that of the control group. The anxiety and depression scores of the experimental group were lower than those of the control group, with the difference being statistically significant ( P<0.05), which suggested that the experimental group showed improvement in anxiety and depression in comparison with the control group. Regarding the quality of life, there were significant differences between the two groups in the scores for the functional dimension ( F=109.798, P<0.001), the symptom dimension ( F=106.936, P<0.001), other items ( F=78.798, P<0.001), and overall health dimensions ( F=174.307, P<0.001). At 1 week and 1 month after surgery, the experimental group had higher scores for the functional dimension and lower scores for the symptom dimension than the control group did, with the differences being statistically significant ( P<0.05). The overall health status of the experimental group was better than that of the control group.

Conclusion

Precision nursing strategies based on multidisciplinary collaboration model can effectively help improve the lung function, the mood, and the quality of life of patients in the short term, showing considerable promise for wide clinical application.

The Effects of Listening to the Qur'an in the Postoperative Management of the Patients Undergoing Laparoscopic Cholecystectomy in the Day Surgery Unit

PURPOSE

To determine if listening to verses of the Qur'an during the immediate postoperative period has an effect on patients' anxiety levels, the number of opioids used to control pain, and the length of stay (LOS) in the Post Anesthesia Care Unit (PACU).

DESIGN

Randomized Control Trial. Adult Muslim patients who had undergone a laparoscopic cholecystectomy through the Day Surgery Unit were randomly selected using computer-generated sequence into two groups, interventional and control groups.

METHODS

The control group listened to the natural environment and received Fentanyl for pain relief, and the interventional group listened to the Qur'an recitation and received Fentanyl for pain relief. A total of 112 (79.4%) participants completed the study. The level of the pain and anxiety was measured using the Wong-Baker Faces pain scale and Spielberger State-Trait Anxiety Inventory, respectively. Statistical analysis was conducted using SAS version 9.3 (Statistical Analysis System, SAS Institute Inc, Cary, North Carolina).

FINDINGS

This study compared the effects of Qur'an audio therapy on patients' anxiety levels, opioid consumption, pain, and LOS in the PACU. The findings showed that by listening to chosen verses from the Qur'an in the recovery period post-anaesthesia, anxiety scores were significantly reduced (P = .0001), opiate use was reduced (P = .0081), and overall PACU LOS was also reduced (P = .0083).

CONCLUSIONS

Adding the use of listening to the Qur'an as a complementary therapy is a simple and cost-effective measure to reduce the need for narcotics in the PACU, and reduce the overall PACU length of stay. This intervention benefits the patient, the PACU, and reduces health care organization costs.

Nurses' management of children's acute postoperative pain: A theory of bureaucratic caring deductive study

BACKGROUND

Few studies have examined the translation of nurses' knowledge of pain management into clinical practice or how nurses negotiated the bureaucracy of caring to treat patients' acute pain.

PURPOSE

This study describes factors that influence pediatric nurses' actions in caring for hospitalized children's acute post-surgical pain.

METHOD

Ray's Theory of Bureaucratic Caring provided the theoretical framework for this mixed methods study of ethnography and human factors engineering. Fourteen nurses were observed throughout their shifts (175.5 h) to elucidate humanistic and bureaucratic influences.

FINDINGS

Of 105 pain assessments, nurses intervened with pharmacologic (n = 45) and biobehavioral (n = 13) interventions for pediatric patients' post-surgical pain in less than 11 min; and 25 assessments revealed patients did not have pain. Pain was assessed and no intervention was provided to 4 patients who were asleep, 5 patients who refused, 2 patients who had no ordered analgesics and 10 patients who were assessed prior to peak effectiveness of their prior analgesic. Overall pain was well-controlled. Of the 28 themes identified, the interplay of 6 categorized to the social/cultural humanistic, 7 political, and 6 technologic/physiological bureaucratic dimensions most strongly influenced pain care.

DISCUSSION

To achieve optimal pain care outcomes, nurses' and parents' pain management knowledge was less influential for clinical practice translation than nurses' negotiation of other dimensions of bureaucratic caring.

Evaluating the relationship between empathy, pain knowledge and attitudes among nursing students

BACKGROUND

It is essential for nurses to manage pain effectively. Nurses start to learn about pain while still students. Pain assessment is more effective with knowledge of pain, positive attitude, and empathy. Nurse educators should evaluate nursing students' knowledge and attitudes toward pain management and their relationship with empathy and should revise the curriculum accordingly. No published studies have been found to date where the relationship between nursing students' knowledge and attitudes toward pain and empathy has been investigated.

OBJECTIVES

This aim of this study was to determine the factors affecting pain knowledge and attitudes of nursing students, and to evaluate the relationship between students level of empathy and pain knowledge and attitudes.

DESIGN

This study was a quantitative, descriptive-correlation design.

SETTINGS AND PARTICIPANTS

The study population was 150 students who were studying in the third and senior grades a nursing department in North Cyprus. The sample included 133 nursing students.

METHODS

Data were collected with the 'Student Descriptive Information Form', 'Knowledge and Attitude about Pain' questionnaire, and the "Basic Empathy Scale" (BES). The data were evaluated with descriptive analysis, nonparametric tests, and correlation analysis by using SPSS 20.0 program.

RESULTS

Mean affective and cognitive empathy scores were 30.16 (SD = 4.42) and 29.29 (SD = 2.65), respectively, and the mean score obtained from the Nurses' Knowledge and Attitudes Survey Regarding Pain was 13.50 (SD = 3.22). Furthermore, 91% of the participants stated that the patient is the most accurate judge of the intensity of pain, but only 1.5% of them responded correctly to questions on pharmacological methods of pain therapy. A weakly positive correlation was found between cognitive (r = 0.100, p = 0.252) and affective (r = 0.013, p = 0.881) empathy levels and pain knowledge and attitudes; nevertheless, this was not statistically significant (p > 0.05).

CONCLUSIONS

The study results indicate that curricula regarding pain management should improve the knowledge and attitudes of nursing students toward pain management. Seminars and practical training about how to use empathy in pain management should be planned and clinical practice should be scheduled more frequently.

Quality Indicators (QI) of Acute Pain after Surgery in European Countries

OBJECTIVES

It is common practice to use pain quality indicators (QI) to accurately assess the medical care situation of patients. This literature review identifies the status quo of acute pain QI among adult inpatients.

DATA SOURCES

Studies published in English or German were identified using a systematic search on CINAHL, Cochrane Library, PubMed, Web of Science, and Google Scholar from 01/2007 to 02/2018. Additional pain management journals, conference proceedings, and websites of health organizations and pain societies were manually screened. Studies about postoperative pain in adults (≥18 years) during inpatient stay after all types of surgery in Europe were included in this review.

REVIEW/ANALYSIS METHODS

The identified study results were categorized into structural, process, and outcome indicators based on Donabedian's framework of evaluating care quality.

RESULTS

The search identified 319 citations, of which 20 studies used structure, process, and outcome data including 180,988 patients and 1,970 health care professionals to gain insight into the quality of acute pain management. Overall, 80% used patient surveys to collect data. National data on pain management are reported in five European studies (France [2], the Netherlands, Spain, and Austria).

CONCLUSIONS

European studies comprehensively comparing acute pain management results are currently missing. Thus, this report highlights the need to develop consensus-based quality indicators in management of acute pain, which take into account both the methodologic quality and the relevance to clinical practice.

Intraprocedural Back Pain Associated with Awake Neuroendovascular Procedures

BACKGROUND AND PURPOSE

The prevalence and characteristics of intraprocedural back pain is not well studied in awake patients undergoing neuroendovascular procedures.

METHODS

We performed a prospective study as part of quality improvement initiative in which all patients who underwent neuroendovascular procedures in awake state were inquired regarding presence, severity (using a numeric rating scale score ranging from 0 [no pain] to 10 [worst pain possible]), and location (using anatomical chart) of back pain immediately after the procedure. The primary endpoint was the proportion of patients with moderate to severe pain (score of ≥3).

RESULTS

A total of 100 (41.3%) of 242 patients reported intraprocedural back pain with a median severity of 5/10 (range 1-10). The mean age was 58.7 ± 16.2 years. The mean duration of the procedure was 82.3 minutes (range 15-410 minutes). The pain was classified as moderate to severe in 86 of 100 patients. The locations of pain were identified in lumbar (n = 77), thoracic (n = 6), cervical (n = 7), cervical and lumbar (n = 8), and cervical with thoracolumbar (n = 2) regions. There was a significant relationship between patients' history of the previous neck and/or back surgery and frequency of moderate to severe back pain (P = .02). No significant relationship was observed between frequency of none to mild and moderate to severe back pain among the strata by patients' age, body mass index, or duration of procedures.

CONCLUSIONS

The relatively high prevalence of intraprocedural back pain in patients undergoing neuroendovascular procedures in awake state must be recognized, and strategies to reduce the occurrence need to be identified.

A Scoping Review of Pain Management Education Programs (PMEPs): Do They Prepare Nurses to Deal with Patients' Postoperative Pain?

This is a report of a scoping review undertaken to obtain an overview of studies conducted on pain management education programs (PMEPs). The aim of this review was to describe existing research publications relating to PMEP to map how pain management practice training might directly influence surgical nurses in contributing to successful pain outcomes in patients. The initial search of electronic databases identified 40 articles according to the inclusion criteria and search strategy, which applied the following terms: (“Pain management education program”) AND^∗ OR^∗ (“Nurses”) AND^∗ OR^∗ (“Patient outcomes”) AND^∗ (“Mixed methods”). Titles, abstracts, and keywords were also searched for the term “Nurse education.” After applying exclusion criteria, five relevant peer-reviewed articles were eventually selected for the final charting of the data. The search included articles published between January 2015 and March 2019. The results show that PMEPs employ a variety of computer-based simulation, web-based facilitation, and video materials based on an evidence-based approach in their syllabuses. PMEPs were shown to enhance practice by promoting improved skills in critical thinking, leadership, patient management, and health promotion. Additionally, these programs promote an ability to practice across a variety of inpatient and outpatient settings, wherein nurses' engagement in managing patients' pain increased after completing the PMEP. Research within PMEP indicates that these programs may contribute to promoting opportunities for new collaborations within multidisciplinary team projects. Additionally, further research initiatives are needed to explore various aspects of these programs to enhance the nursing skills required for effective pain management, such as computer-based simulation, web-based facilitation, and video materials. Moreover, research relating to PMEPs in low- and middle-income countries is scarce and warrants further study.

Opioid use disorder education for acute care nurses: An integrative review

AIMS AND OBJECTIVES

The purpose of this study was to explore opioid use disorder (OUD) education programmes presented to practicing nurses working in medical-surgical settings and identify the methods used to evaluate their effectiveness.

BACKGROUND

Health professionals often express negative attitudes towards patients with OUD which can lead to suboptimal care. Education decreases negative attitudes of healthcare workers. Despite this, few educational programmes are offered to promote knowledge among acute care nurses who work in medical-surgical settings and provide care to patients with OUD.

DESIGN

An integrative review.

METHODS

The framework by Whittemore and Knafl was used to examine empirical literature between 1995-2019 to answer the research questions, (a) What types of education do acute care nurses receive regarding OUD? (b) What methods are used for measuring educational intervention effectiveness? CINAHL, ERIC, PsycINFO and MEDLINE were searched using combinations of search terms and PRISMA guidelines. The initial 394 articles were narrowed to nine from the United States and Australia that met the search criteria and purpose of the review.

RESULTS

Educational programmes used to promote knowledge included interactive workshops, case studies, online modules, simulation sessions, real-time coaching and in-service trainings. Methods used to measure effectiveness of educational interventions were self-assessment tools that measured pre/postknowledge, attitude surveys, alcohol and drug scales and individual researcher-developed instruments.

CONCLUSIONS

Additional research is needed to determine best teaching strategies for increasing knowledge of OUD and OUD patient care. Valid and reliable methods for measuring effectiveness of OUD educational interventions are inadequate.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of OUD has been linked to positive patient outcomes and nurses would benefit from up-to-date educational offerings. Opioid use disorder is a growing global concern. Translation of current OUD nursing science to acute care nurses would promote health equity in practice for individuals with OUD.

Quo Vadis PCA? A Review on Current Concepts, Economic Considerations, Patient-Related Aspects, and Future Development with respect to Patient-Controlled Analgesia

This review assesses four interrelating aspects of patient-controlled analgesia (PCA), a long-standing and still widely used concept for postoperative pain management. Over the years, anaesthesiologists and patients have appreciated the benefits of PCA alike. The market has seen new technologies leveraging noninvasive routes of administration and, thus, further increasing patient and staff satisfaction as well as promoting safety aspects. Pharmaceutical research focuses on the reduction or avoidance of opioids, side effects, and adverse events although influence of these aspects appears to be minor. The importance of education is still eminent, and new educational formats are tested to train healthcare professionals and patients likewise. New PCA technology can support the implementation of efficient processes to reduce workload and human errors; however, these new products come with a cost, which is not necessarily reflected through beneficial budget impact or significant improvements in patient outcome. Although first steps have been taken to better recognize the importance of postoperative pain management through the introduction of value-based reimbursement, in most western countries, PCA is not specifically compensated. PCA is still an effective and valued technique for postoperative pain management. Although there is identifiable potential for future developments in various aspects, this potential has not materialized in new products.

Optimizing opioid prescribing and pain treatment for surgery: Review and conceptual framework

Purpose

Millions of Americans who undergo surgical procedures receive opioid prescriptions as they return home. While some derive great benefit from these medicines, others experience adverse events, convert to chronic opioid use, or have unused medicines that serve as a reservoir for potential nonmedical use. Our aim was to investigate concepts and methods relevant to optimal opioid prescribing and pain treatment in the perioperative period.

Methods

We reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts.

Results

Opioid prescribing and pain treatment after discharge from surgery broadly consist of 3 key interacting perspectives, including those of the patient, the perioperative team, and, serving in an essential role for all patients, the pharmacist. Systems-based factors, ranging from the organizational environment’s ability to provide multimodal analgesia and participation in enhanced recovery after surgery programs to other healthcare system and macro-level trends, shape these interactions and influence opioid-related safety outcomes.

Conclusions

The severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the United States. Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient. Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that contributes to the most pressing public health crisis of our time.