Acute Pain Management: Impact of Opioid Tolerance Leveling on Patient, Provider, and System Outcomes

The human and economic burden related to ineffective pain management is well documented.   Factors influencing ineffective acute pain management are multi-factorial and include failure of healthcare professionals to accurately and reliably  assess and meet patient’s individual pain management requirements.  The discipline has been absent an approach and tools enabling reliable, safe, patient-centric assessment and management of pain.  Historically, acute pain treatment is focused on the primary admitting condition, which can inadvertently exacerbate existing addiction and improperly manage the patient pain needs.  This further potentiates provider biases that conflict with evidence-based pain management strategies.   To address these concerns, an interprofessional team was assembled including direct care nurses, clinical nurse specialists, chemical dependency consultants, educators, pharmacists, physicians and hospital leadership.  A system pilot was designed with a four prong approach: education of the provider of opioid selection and utilization, tiered approach for assessment of patient experience and tolerance with opioids, consistent and reliable evidenced based selection and administration of opioids, structure and processes enabling surveillance and escalation of pain management.  Tiers are assigned based on patients’ daily use of opioids. The program uses a systematic, reliable, evidence-based approach to expedite treatment options and interprofessional consultation to design a plan customized to the patient’s needs through clearly defined orders.  Information system tools were developed to aid transparency and access to data that supports evidence based pain management.  An escalation process was created to identify variances and build a robust learning cycle for enhanced program reliability.  Program evaluation measures include the following:  patient experience (harm composite and satisfaction scores), provider (rate of adoption and nursing knowledge).  Preliminary results (n=400) reveal high provider satisfaction, wide-spread adoption, and most importantly improved patient experience including a zero percentage harm composite. Clinical scholarship aligning and integrating implementation science and innovation has the capacity to advance the practice of nursing, patient care delivery, and most importantly exceed the needs of those we are privileged to serve.  Additionally, providers can customize standardized pain pathways with less bias while maintaining autonomy in practice and promoting a consistent plan of care across the continuum.