Unique approaches to improve pain management in hospitals and clinical practices

Five recent Johns Hopkins University School of Nursing DNP graduates have taken different and unique approaches in working to improve the implementation of pain management in hospitals and clinical practices.

Shawna Mudd, DNP '10, CPNP, evaluated alternatives to IV injections for pain control in pediatric emergency departments. Her solution was to alleviate one of the biggest fears of children: needles. The use of intranasal fentanyl (INF) affords the children a less invasive option. Instead of the pain of an IV or a shot to administer pain medication, INF is simply the injectable form of the medicine sprayed into the nose. According to Mudd, the use of INF is becoming more popular. "It has become a standard practice in the pediatric emergency department here at Hopkins and is put into practice in many places throughout the country," she said. "I have shared my protocol and review of the literature with many hospitals (particularly in Maryland) who are interested in implementing it as well. Hopefully, INF can be applied in more areas (outside the emergency department) to address pain in children."

Brett Morgan, DNP '09, CRNA, sought to decrease pain and significantly cut down post-op discharge time through a regimen of medications. The combination of medication, 1200 mg Gabapentin, 1000 mg Tylenol, and 800 mg Celoxib, which was administered prior to surgery to 17 of 34 patients evaluated, resulted in several benefits. "The three most significant results reported were a significant decrease in total pain medication given to patients, both during surgery and after surgery; a significant decrease in the total time a patient needs to reach discharge requirements for those who received the preemptive medications; and less reported pain while in the recovery room," Morgan said. The project was conducted at Wake Med Cary Hospital in Cary, NC and the regimen is being used by practitioners at multiple hospitals in the Raleigh, NC area.

Claudette Jacobs, DNP '10, RN, aimed to improve electronic documentation that assessed pain management by incorporating all three components of the AIR cycle (assessment, intervention and reassessment). The original electronic documentation was separated into two screens: one featuring assessment and intervention followed by a screen that recorded evaluation. Jacobs said that nurses often failed to use the second screen and wanted to fix that problem. "About 50% of patients in moderate-to-severe pain will remain in moderate-to-severe pain often because of failure of reassessment and needed intervention. Incorporating all three into one screen was aimed to improve the continuous need to assess, intervene and reassess pain on an ongoing basis," she said.

Mary Jean Schumann, DNP '10, MBA, worked to develop a quality measure for relief of acute pain in hospitalized children. In four hospitals, pain scale scores were collected from 101 children between the ages of three to 19 who were hospitalized for at least 24 hours. Of the 101 children, 41 reported scores of greater than zero. Schumann said three fourths of the 41 children had some kind of intervention and, of that group, 61% had at least a 20% reduction in their pain score. Schumann said more younger children experienced pain reductions than older children. She attributes the reductions to nurses using observable measures of pain for the younger children tested, rather than going by the children's reports. The older children who reported their own pain were less likely to receive medication. "I found that nurses need to be more consistent and timely in reassessing pain response to intervention, and I learned nurses often do not use the most appropriate pain scale for the age and development of the particular child," Schumann said. "(This work) points the way to more exploratory study and highlights issues needing to be addressed. Nurses think we could do better with managing children's pain issues and these findings point to some specific things we can do to make a difference," she said.

Diana Meyer, DNP '12, RN, assessed the effects of complementary therapies, specifically music, as a tool to improve pain management. Meyer tested 23 patients in a baseline group without music and 23 patients with non-lyrical music intervention ranging from piano, harp, guitar, saxophone, and Native American flute. Patients who received music were more satisfied with pain management than patients who did not have music by a rate of 65% vs. 48%. According to Meyer, 100% of the patients in the music group would use music again for pain management when hospitalized. "These results demonstrate that it does not take a lot more time or money to make a positive impact on the patient's pain experience," Meyer said. "While the level of pain did not decrease, and I did not expect it to, the fact that patients expressed more comfort while still experiencing pain is significant. There is a strong emotional component to the pain experience and using a music intervention has the potential to strengthen the patient's ability to get through painful experiences with more comfort and be more satisfied with nurses' efforts to manage their pain." Meyer added that following the evaluation, nurses were more willing to make time to implement music therapy into their workflow, a marked improvement over the resistance they had shown before the new pain management practices began.