Pain and Satisfaction With Pain Management Among Older Patients During the Transition From Acute to Skilled Nursing Care

Almonertinib as a neoadjuvant therapy for patients with a superior pulmonary sulcus tumor with activated EGFR mutation: A case report

A superior pulmonary sulcus tumor, also known as a Pancoast tumor, invades tissues or organs at the entrance of the thorax, such as the brachial plexus, upper ribs, vertebrae, subclavian vessels and stellate ganglia. Induction concurrent chemoradiotherapy followed by radical surgical resection is the preferred treatment. The present study reported the case of a 52-year-old male who presented at Hubei Cancer Hospital, Tongji Medical College (Wuhan, Hubei) with left chest pain and an abnormal chest computed tomography scan showing a mass of 81x43 mm in the left upper chest wall that invaded the first, second and third anterior ribs. Biopsy of the mass showed stage cT4N0M0, IIIA, poorly differentiated adenocarcinoma and epidermal growth factor receptor+. The patient was treated by induction chemotherapy and targeted therapy, which was followed by surgical resection of the left upper lobe and the affected chest wall via the transmanubrial approach. The targeted therapy with almonertinib was continued postoperatively. To date, no disease recurrence has been detected during the 4 months follow-up.

Behavioral Health Services with Short-Stay Residents in Skilled Nursing Facilities: A Qualitative Study of Clinicians and Administrators

OBJECTIVES

The perspectives of professionals involved in behavioral health (BH) services with short-stay residents in skilled nursing facilities (SNFs) are rarely captured in the literature. This study examines the real-world experiences of BH clinicians and administrators in post-acute/subacute care units in SNFs.

METHODS

This qualitative study used semi-structured interviews with 18 clinicians (e.g., psychologists and social workers) and five administrators (e.g., directors of social services or BH company executives) involved in BH services with short-stay SNF residents. Interviews were recorded, transcribed, and analyzed by two independent coders using conventional thematic content analysis.

RESULTS

Three themes emerged from the data: (1) BH needs are high among short-stay residents and families during post-acute care transitions; (2) BH services offer multiple unique opportunities to enhance post-acute/subacute care in SNFs; and (3) barriers to providing optimal BH care exist at multiple levels and require action from BH clinicians and stakeholders.

CONCLUSIONS

Variability in clinician roles and barriers to optimized care suggest the need for future research targeting best practices and implementation strategies for BH services with short-stay SNF residents.

CLINICAL IMPLICATIONS

Results identified multiple ways in which BH services may enhance resident, family, and staff outcomes, as well as the milieu in SNFs.

Music for your mental health? The development and evaluation of a group mental health intervention in subacute rehabilitation

Objectives: Short-stay residents of nursing homes experience high rates of mental health (MH) distress compared to community dwelling counterparts, yet MH interventions are difficult to implement and sustain. We modified a music therapy framework to Effective Music in Psychotherapy. Using the modified model, we integrated music listening into MH group intervention and evaluated MH outcomes. This pilot study reports the development and evaluation of the Mental Health and Music Group for short-stay nursing homes residents.Method: The group was developed and refined to be non-sequential and non-cumulative, specific to the needs of short-stay nursing home residents. Pre-/post-session ratings examined affect, quality of life, and pain. Leaders monitored engagement across and between sessions. Qualitative interviews were conducted with a selection of attendees.Results: Findings indicated decreases in irritation and worry, and increases in mood, energy, and self-as-a-whole from pre- to post-session. There were no changes in pain, perception of physical health or life-as-a-whole, energetic, sad, or happy affect, or differences in engagement. Qualitative interviews demonstrated benefits of group modality and music to group cohesion and highlighted the relevance of music for mental health outcomes.Conclusion: The Mental Health and Music group was designed around a framework of Effective Music in Psychotherapy, for short-stay nursing home settings, and demonstrated promising results. Future research can solidify the interventions generalizeability to medical and rehabilitation settings addressing the specific population needs and preferences.Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2021.1935463 .

Older Patient Satisfaction with Chronic Pain Management in the National Geriatric Hospital in Vietnam

PURPOSE

The high prevalence of chronic pain and difficulties in pain management in older people are challenging for healthcare providers globally. Patient satisfaction regarding pain management is one of the measures to assess efficacy of pain control as well as healthcare services. Thus, our study aimed to evaluate the older patients' satisfaction with pain management and its associated factors in Vietnam.

PATIENTS AND METHODS

A cross-sectional study was conducted at National Geriatric Hospital, Hanoi, Vietnam from May to October 2018. Face-to-face interviews were conducted on 495 older patients with chronic pain by using a structured questionnaire. The Pain Treatment Satisfaction Scale (PTSS) was used to assess the level of satisfaction with pain management. A Tobit regression model was used to estimate factors associated with satisfaction toward pain management.

RESULTS

The mean total satisfaction score was 1.77 (SD= 0.22). Older patients were most satisfied with the aspect of side effects of pain relief medication (mean=0.66, SD=0.56). On the contrary, they were most dissatisfied with information provided about pain and its treatment and efficacy of pain relief medication. Outpatients were less satisfied with information provided, the impact of current medication and pain management in general compared to inpatients. The regression model showed that patients with severe pain tended to be more dissatisfied with pain management than those with no pain.

CONCLUSION

This study indicated that the general satisfaction with chronic pain management in older patients was quite good especially in the aspect of pain medication's side effects. However, dissatisfactory factors remained, including information provided about pain and efficacy of current pain medication. Intensive training regarding pain in geriatric care, health education communication for older people, and improved quality of medical services should be performed to ensure the quality of pain management, especially in the older population.

Bundling Interventions to Enhance Pain Care Quality (BITE Pain) in Medical Surgical Patients

Background: Inadequate pain management and undertreatment remain a serious clinical issue among hospitalized adults, contributing to chronic pain syndromes and opioid dependency. Implementation of individual pain care interventions has been insufficient to improve pain care quality. The purpose of this interprofessional, patient-centered project was to implement a 6-component bundle of evidence-based pain management strategies to improve patients' perception of pain care quality and 24-hour pain experience outcomes. Methods: A quasi-experimental design was used to test the effect of a bundled pain management intervention on 3 medical surgical units. Baseline outcomes using the Pain Care Quality-Interdisciplinary (PainCQ-I^©) and Pain Care Quality-Nursing (PainCQ-N^©) surveys were measured monthly for 4 months preintervention and 30 months postintervention. Results: A convenience sample of 846 patients was analyzed. The effect of the intervention on pain outcomes could not be tested because unit-based adherence did not meet the goal of 80%. A subsample of 70.2% (594/846) of participants was sufficient to complete a 3-group analysis of preintervention and postintervention participants with confirmed intervention adherence. Participants in the postintervention group who received all 6 components (n=65) had significantly higher odds of higher PainCQ^© scores than those in the preintervention group (n=141) (PainCQ-I^©: odds ratio [OR] 2.61, 95% confidence interval [CI] 1.54-4.42; PainCQ-N^©: OR 3.82, 95% CI 2.06-7.09) or those in the postintervention group receiving ≤5 components (n=388) (PainCQ-I^©: OR 2.52, 95% CI 1.57-4.03; PainCQ-N^©: OR 3.84, 95% CI 2.17-6.80). Conclusion: Medical surgical patients participating in this study who received the bundled 6-component intervention reported significantly higher levels of perceived pain care quality, suggesting that a bundled approach may be more beneficial than unstandardized strategies.

Analgesic Use Patterns Among Patients With Dementia During Transitions From Hospitals to Skilled Nursing Facilities

Gaps in pain management, including discontinuity in analgesic medication prescribing, frequently complicate transitions from hospital to skilled nursing facilities (SNFs) for patients with dementia. The objective of the current study was to examine analgesic medication use and prescribing patterns in the last 48 hours of hospitalization and upon discharge to SNF among stroke and hip fracture patients with dementia. Of 318 patients who received an analgesic medication within the last 48 hours of hospitalization, 23% experienced potentially abrupt discontinuations upon discharge. These rates varied by medication, with acetaminophen with codeine (27%), hydromorphone (19%), and acetaminophen with hydrocodone (19%) having the highest rates of potentially abrupt discontinuations. Conversely, 38% of patients experienced potentially abrupt additions of an analgesic medication upon discharge. Findings suggest that changes to analgesic regimens prior to and upon discharge may be common practice, potentially hindering care continuity and pain control during transitions. [Res Gerontol Nurs. 2019; 12(2):61-69.].

Have you SCAND MMe Please? A framework to prevent harm during acute hospitalisation of older persons: A retrospective audit

AIMS AND OBJECTIVES

To test the mnemonic Have you SCAND MMe Please? as a framework to audit nursing care to prevent harms common to older inpatients.

BACKGROUND

It is not known if acute hospital care comprehensively addresses eight interrelated factors that contribute to preventable harms common in older hospitalised patients.

DESIGN

Retrospective audit of medical records.

METHODS

A random selection of 400 medical records of inpatients over 65 years of age with an unplanned admission of longer than 72 hr in acute medical wards at four hospitals in Victoria, Australia, during 2011-12, was examined for frequency of documented evidence of assessments, interventions or new problems related to eight factors contributing to common preventable harms during hospitalisation.

RESULTS

Assessments of skin integrity (94%-97%), mobility (95%-98%) and pain (93%-97%) were most often documented. Gaps in assessment of continence (4%-31%), nutrition (9%-49%), cognition (delirium, depression and dementia) (10%-24%) were most common. No patient record had evidence of all eight factors being assessed. Almost 80% of records had interventions documented for one or more factors that contribute to preventable harms. In almost 20% of patient records, a new preventable harm was documented during hospitalisation.

CONCLUSIONS

The mnemonic Have you SCAND MMe Please? brings together eight factors known to contribute to preventable harms common in older hospitalised patients. This framework was useful to identify gaps in assessment and interventions for factors that contribute to preventable harms during acute hospital care. Future research should test if the mnemonic can assist nurses with comprehensive harm prevention during acute hospitalisation.

RELEVANCE TO CLINICAL PRACTICE

The mnemonic Have you SCAND MMe Please? represents eight factors that contribute to preventable harms common in older hospitalised patients. This framework provides a model for harm prevention to assist nurses to implement comprehensive harm prevention to improve quality of care and safety for older hospitalised patients.

Prevalence and Characteristics of Moderate to Severe Pain among Hospitalized Older Adults

OBJECTIVES

To investigate the prevalence, characteristics, and management of pain in older hospitalized medical patients.

DESIGN

Medical record aggregate review.

SETTING

Tertiary care hospital.

PARTICIPANTS

Individuals aged 65 and older admitted to the medicine service between November 28, 2014, and May 28, 2015.

MEASUREMENTS

Demographic characteristics, comorbidity burden, pain characteristics, and analgesics during index hospitalization were assessed in individuals with moderate to severe pain (≥4 on 0-10 Numeric Pain Rating Scale).

RESULTS

Of 1,267 patients admitted to the medicine service, 248 (20%) had moderate to severe pain on admission (mean age 75 ± 8, 57% female, 50% white). During hospitalization, most participants received opioids (80%) and acetaminophen (74%), and few received nonsteroidal antiinflammatory drugs (9%). Participants with chronic pain had less reduction in pain intensity score from admission to discharge than those without a history of chronic pain (mean change score 3.7 vs 4.9, p=.002) and were more likely to receive opioids, adjuvant analgesics, and other analgesics (all p<.05).

CONCLUSION

Twenty percent of older adults admitted to a general medicine service had moderate to severe pain. Further research about optimal pain management in hospitalized older adults, particularly those with chronic pain, is necessary to improve care in this population.

Minimal Use of Opioids for Pain Relief in an Internal Medicine Department

OBJECTIVES

The objective of the study was to determine if pain control was adequate despite our policy of limited opioid use.

METHODS

In this observational cohort study, we reviewed 300 consecutive patient charts from an internal medicine department. We extracted demographic data, as well as the patients' primary diagnosis, pain on admission, daily pain evaluations (numerical rating score [NRS]), and treatment. Significant pain was defined as a score of ≥3 on the NRS. We determined the incidence of pain and pain control and reviewed the charts of those with an NRS ≥3 for ≥3 days to determine the need for opioid therapy.

RESULTS

Of 1692 total hospitalization days in the 300 consecutive patients with a median age of 80 years (1st-3rd quartiles, 65-87 years) there were 204 days with complaints of pain (12.1%) and 149 days (8.8%) with reports of pain of ≥3 on the NRS. Overall, 28.3% (85 of 300) of the patients had significant pain during their hospitalization. Most of the pain, however, (80.0%, 68 of 85) was short-term (1-2 days) whether or not the patient received pain medication. Pain relief treatment in the hospital included opioids in 17 (5.7%, 95% confidence interval [CI] 3.5-8.9) and dipyrone in 36 (12%, 95% CI 8.8-16) of the 300 patients. Pain control was adequate in the seven patients with prolonged pain who did not receive opioids. There were only two patients discharged with prescriptions for opioids (0.7%, 95% CI 0.2-2.6).

CONCLUSIONS

Significant pain is common in patients hospitalized in an internal medicine department, but the pain is mostly short term and pain control is adequate despite the restricted use of opioid therapy during hospitalization.

Shifting Paradigms: Advance Care Planning for Pain Management in Older Adults With Dementia

Ensuring effective pain management is an important quality of life (and death) issue for older adults with dementia, particularly since they are more vulnerable to under-assessment and under-treatment of pain. Yet, pain management decisions are often made by health care providers and caregivers with little to no input on the older adult's with dementia values for pain management. The Institute of Medicine (IOM) has recognized the revolutionary imperative to change the manner in which pain care is planned and coordinated. Implementing advance care planning (ACP) prior to advanced stages of dementia may assist in developing a person-centered pain management plan and improve pain care for this population throughout the dementia trajectory. This forum overviews the current state of pain management in dementia, discusses the significance of ACP in a pain management context, and offers practical solutions for common challenges in ACP. Dementia in this article is an umbrella term referring to the many forms of dementiathat cause cognitive impairment.

Self-report pain assessment tools for cognitively intact older adults: Integrative review

BACKGROUND

Pain is common in older adults, but it is often underreported or undertreated partly because many consider pain to be a normal consequence of ageing. Among the plethora of available self-report pain assessment tools, there is no synthetised evidence which tools are indicated for use among cognitively intact older adults.

PURPOSE OF THE STUDY

To understand documented self-report pain assessment tools that have been used among cognitively intact older adults, and to describe their characteristics including overall performance as well as studies demonstrating their use.

METHODS

A systematic search of the indexed databases PubMed, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus) was conducted to identify documented self-report pain assessment tools through peer-reviewed papers, including citations from January 1990 to December 2015. Thirty-five percentage of abstracts were independently evaluated by two raters according to specific criteria.

RESULTS

Among identified tools, the Iowa Pain Thermometer, the 6-point Verbal Descriptor Scale, the Numeric Rating Scale, the short form Brief Pain Inventory (BPI) and the Geriatric Pain Measure (GPM) may be suitable tools for self-reported pain by cognitively intact older adults based on the statement of the literature. Only two self-report tools (the GPM and the Geriatric Painful Events Inventory) were designed specifically for older adults.

CONCLUSIONS

More studies are needed to evaluate pain measures' psychometric performance across different settings, racial/ethnic groups and disease categories. Since 80% of older adults have at least one chronic disease, multidimensional tools such as the GPM may need to be used more often for accurate self-report of pain.

IMPLICATIONS FOR PRACTICE

Examining the psychometric properties of comprehensive self-report pain assessment tools informs recommendations for the selection of tools to be used in clinical practice.

Assessment and Measurement of Pain in Adults in Later Life

Pain in aging adults is a global health problem requiring a proactive and consistent assessment approach. Pain assessment is critical to detecting pain and developing a collaborative and adaptive pain management plan. Getting health providers to assess and measure pain even in older adults who are communicative and can self-report remains a challenge. Self-report is the best method for identifying pain. Using a validated pain assessment scale is key to evaluate pain intensity. This article discusses techniques to obtain self-report and describe appropriate self-report pain tools for a focused pain assessment and reassessment in adults in later life.

Challenges for Nurses Caring for Individuals with Peripherally Inserted Central Catheters in Skilled Nursing Facilities

OBJECTIVES

To understand the perceived preparedness of frontline nurses (registered nurses (RNs), licensed practical nurses (LPNs)), unit nurse managers, and skilled nursing facility (SNF) administrators in providing care for residents with peripherally inserted central catheters (PICCs) in SNFs.

DESIGN

Exploratory, qualitative pilot study.

SETTING

Two community based SNFs.

PARTICIPANTS

Residents with PICCs, frontline nurses (RNs, LPNs), unit nurse managers, and SNF administrators.

METHODS

Over 36 weeks, 56 residents with PICCs and their nurses were observed and informally interviewed, focusing on PICC care practices and documentation. In addition, baseline PICC data were collected on placement indication (e.g., antimicrobial administration), placement setting (hospital vs SNF), and dwell time. Focus groups were then conducted with frontline nurses and unit nurse managers, and semistructured interviews were conducted with SNF administrators to evaluate perceived preparedness for PICC care. Data were analyzed using a descriptive analysis approach.

RESULTS

Variations in documentation were observed during weekly informal interviews and observations. Differences were noted between resident self-reported PICC concerns (quality of life) and those described by frontline nurses. Deficiencies in communication between hospitals and SNFs with respect to device care, date of last dressing change, and PICC removal time were also noted. During focus group sessions, perceived inadequacy of information at the time of care transitions, limited availability of resources to care for PICCs, and gaps in training and education were highlighted as barriers to improving practice and safety.

CONCLUSION

Practices for PICC care in SNFs can be improved. Multimodal strategies that enhance staff education, improve information exchange during care transitions, and increase resource availability in SNFs appear necessary to enhance PICC care and safety.