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Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial.

ABSTRACT: To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies.A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only.Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership.Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group.Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later.Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention.Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

SUBMITTER: Ersek M

PROVIDER: S-EPMC4988793 | biostudies-literature | 2016 Apr

REPOSITORIES: biostudies-literature

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Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial.

Ersek Mary M Neradilek Moni Blazej MB Herr Keela K Jablonski Anita A Polissar Nayak N Du Pen Anna A

Journal of the American Medical Directors Association 20160217 4

<h4>Objective</h4>To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies.<h4>Design</h4>A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only.<h4>Setting</h4>Twenty-seven NHs in the greater Puget Sound area participated. Facilities ...[more]

PMID: 26897592

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Project description:BACKGROUND:For nursing home (NH) residents with swallowing or chewing problems, appealing texture-modified-diets (TMD) need to be available in order to support adequate nutrition. The aim of this study was to describe the availability of TMD and best practices for TMD in German NHs and to identify related NH characteristics. METHODS:Information on NH characteristics, available texture-modified (TM)-levels (soft, "minced & moist", pureed) and implemented best practices for TMD (derived from menu plan, separately visible components, re-shaped components, considering individual capabilities of the resident) was collected in a survey in German NHs. The number of TM-levels as well as the number of best practices for TMD were tested for their association with 4 structural, 16 operational and 3 resident-related NH characteristics. RESULTS:The response rate was 7.2% (n?=?590) and 563 NHs were included. The vast majority of NHs (95.2%) reported offering "minced & moist" texture and 84.2% preparing separately visible meal components. Several operational characteristics were more frequently (p?<?0.05) reported from NHs offering three TM-levels (27.7%) or four best practices for TMD (13.0%) compared to NHs offering one TM-level (28.4%) or one best practice for TMD (20.1%): special diets and delivery forms (e.g. fingerfood 71.2% vs 38.8%; 80.8% vs. 44.3%), written recipes (69.9% vs. 53.1%; 68.5% vs. 53.9%), a dietetic counseling service (85.9% vs. 66.3%; 89.0% vs. 65.2%), a quality circle for nutritional care (66.7% vs. 43.8%; 71.2% vs. 50.4%), regular staff training (89.7% vs. 73.1%; 95.9% vs. 74.8%) and process instructions (73.7% vs. 53.1%; 75.3% vs. 47.8%). No associations were found regarding structural and resident-related NH characteristics, except a higher percentage of residents receiving TMD in NHs with three compared to one TM-level (median 16.3% vs. 13.2%, p?=?0.037). CONCLUSION:All participating NHs offer some form of TMD, but only a small number offers a selection of TMD and pays adequate attention to its preparation. Operational NH characteristics - which might reflect a general nutritional awareness of the NH - seem to be pivotal for provision of TMD, whereas neither structural nor resident-related characteristics seem to play a role in this regard.

Project description:BackgroundUnrelieved pain among nursing home (NH) residents is a well-documented problem. Attempts have been made to enhance pain management for older adults, including those in NHs. Several evidence-based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults. Despite the proliferation and dissemination of these practice guidelines, research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting. One promising approach is the embedding of guidelines into explicit protocols and algorithms to enhance decision making.PurposeThe goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence-based pain assessment and management practices, decreasing pain and depressive symptoms, and enhancing mobility among NH residents.MethodsThe study used a cluster-randomized controlled trial (RCT) design in which the individual NH was the unit of randomization. The Roger's Diffusion of Innovations theory provided the framework for the intervention. Outcome measures were surrogate-reported usual pain, self-reported usual and worst pain, and self-reported pain-related interference with activities, depression, and mobility.ResultsThe final sample consisted of 485 NH residents from 27 NHs. The investigators were able to use a staggered enrollment strategy to recruit and retain facilities. The adaptive randomization procedures were successful in balancing intervention and control sites on key NH characteristics. Several strategies were successfully implemented to enhance the adoption of the algorithm. LIMITATIONS/LESSONS: The investigators encountered several methodological challenges that were inherent to both the design and implementation of the study. The most problematic issue concerned the measurement of outcomes in persons with moderate to severe cognitive impairment. It was difficult to identify valid, reliable, and sensitive outcome measures that could be applied to all NH residents regardless of the ability to self-report. Another challenge was the inability to incorporate advances in implementation science into the ongoing studyConclusionsMethodological challenges are inevitable in the conduct of an RCT. The need to optimize internal validity by adhering to the study protocol is compromised by the emergent logistical issues that arise during the course of the study.

Project description:Objective: To develop an evidence-based clinical practice guideline (CPG) through a broad-based consensus process on best practices for chiropractic management of patients with chronic musculoskeletal (MSK) pain. Design: CPG based on evidence-based recommendations of a panel of experts in chronic MSK pain management. Methods: Using systematic reviews identified in an initial literature search, a steering committee of experts in research and management of patients with chronic MSK pain drafted a set of recommendations. Additional supportive literature was identified to supplement gaps in the evidence base. A multidisciplinary panel of experienced practitioners and educators rated the recommendations through a formal Delphi consensus process using the RAND Corporation/University of California, Los Angeles, methodology. Results: The Delphi process was conducted January-February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions: low-back pain (LBP), neck pain, tension headache, osteoarthritis (knee and hip), and fibromyalgia. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind-body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized. Conclusions: These evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.

Project description:Background and objectivesThe study aimed to: (i) describe whether culture change (CC) practice implementation related to physical environment, resident-centered care, and staff empowerment increased within the same nursing homes (NHs) over time; and (ii) identify factors associated with observed increases.Research design and methodsThis was a nationally representative panel study of 1,584 U.S. NHs surveyed in 2009/2010 and 2016/2017. Survey data were merged with administrative, NH, and market-level data. Physical environment, staff empowerment, and resident-centered care domain scores were calculated at both time points. Multivariate logistic regression models examined factors associated with domain score increases.ResultsOverall, 22% of NHs increased their physical environment scores over time, 32% their staff empowerment scores, and 44% their resident-centered care scores. However, 32%-68% of NHs with below median baseline scores improved their domain scores over time compared with only 11%-21% of NHs with baseline scores at or above the median. Overall, NHs in states with Medicaid pay-for-performance (with CC components), in community care retirement communities, with special care units and higher occupancy had significantly higher odds of increases in physical environment scores. Only baseline domain scores were associated with increases in staff empowerment and resident-centered care scores.Discussion and implicationsThis is the first nationally representative panel study to assess NH CC adoption. Many NHs increased their CC practices, though numerous others did not. While financial incentives and indicators of financial resources were associated with increase in physical environment scores, factors associated with staff empowerment and resident-centered care improvements remain unclear. Studies are needed to assess whether the observed increases in CC adoption are associated with greater quality of life and care gains for residents and whether there is a threshold effect beyond which the efficacy of additional practice implementation may be less impactful.

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Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial.

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Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial.

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