The VA/Department of Defense (DoD) Clinical Practice Guideline for the Management of Postoperative Pain was disseminated in April 2002. Elements of this guideline include evidence-based practices (EBP) that should have been implemented for optimal care. Examples include around-the-clock analgesia administration, patient-controlled analgesia, elimination of prn IM analgesia and meperidine. However, translating these EBP findings into clinical practice remains a gap in pain management practice. Despite the VHA priority of “pain as the 5th vital sign,” results from VA customer feedback surveys suggest that pain remains inadequately managed in surgical settings. In evaluating whether the implementation interventions were successful in the three VISNs, this project will generate knowledge about the best methods to create organizational change nationally.
The objectives of this six-month planning grant are: 1) to identify gaps and barriers in application of evidence from the VA/DoD Postoperative Pain Management Guideline (CPG); and 2) to propose strategies for implementation of specific and strong evidence for postoperative care. At the end of the six months, a proposal was submitted.
Focus groups and chart reviews were conducted over six months in 2004 in five acute care hospitals in three VISNs about evidence application specific to total hip and knee replacement surgeries. Health care providers were grouped by discipline at their facilities to discuss barriers to implementing evidence from the CPG. Barriers were content analyzed for themes.
Chart reviews were done to establish presence of documentation about specifics such as uses of opioids, epidurals, patient-controlled analgesia, non-pharmacologic methods, and pain scores as related to medications. Data analysis included frequency and consistency of documentation of the specific evidence.
Focus groups were conducted individually and in groups. Categories of barriers included issues about: anesthesia and epidurals, patient-controlled analgesia, medications, substance abuse, pain assessments, documentation, non-pharmacologic interventions, clinical reminders, changing practice, pain service availability, education, and communication.
Chart reviews revealed gaps primarily in eight areas: inaccessibility of anesthesia records; patient-controlled analgesia documentation; non-pharmacological methods documentation; use of prn medications; inconsistent opioid administration; use of epidurals; location and consistent documentation of pain scores; and adjustment of medications for opioid-users.
The study findings reveal the need for improvement in postoperative pain management for total hip and knee replacement surgeries. Improvements are needed through policy changes and provider competencies and should focus on change resistance, provider communication, staff education, and documentation. Strategies for translating strong evidence into practice should be tested for effective implementation of changes.
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