Chris Forcucci

Assessing and treating pain in hospices: current state of evidence-based practices

The aim of this study was to report on current provider evidence-based assessment and treatment practices for older adults with cancer in community-based hospice settings. Using the Cancer Pain Practices Index, a tool developed by the researchers to measure evidence-based pain management practices, patients received an average of 32% of those key evidence-based practices (EBPs) that were applicable to their situations. When examining individual practices, most of the patients had their pains assessed at admission using a valid pain scale (69.7%) and had primary components of a comprehensive assessment completed at admission (52.7%); most patients with admission reports of pain had an order for pain medication (83.5%). However, data revealed a number of practice gaps, including additional components of a comprehensive assessment completed within 48 hours of admission (0%); review of the pain treatment plan at each reassessment (35.7%); reassessment of moderate or greater pain (5.3%); consecutive pain reports of 5 or greater followed by increases in pain medication (15.8%); monitoring of analgesic-induced side effects (19.3%); initiation of a bowel regimen for patients with an opioid order (32.3%); and documentation of both nonpharmacological therapies (22.5%) and written pain management plans (0.6%). Findings highlight positive EBPs and areas for improving the translation of EBPs into practice. Data suggest that cancer pain is not being documented as consistently assessed, reassessed, or treated in a manner consistent with current EBP recommendations for older adults with cancer in community-based hospices.

Adults Seeking Presymptomatic Gene Testing for Huntington Disease

Purpose: To describe the expectations of those seeking presymptomatic gene testing for Huntington disease (HD). Identification of the gene for HD makes it possible to conduct testing to determine if a healthy person with a family history of HD has a mutation in this gene. Presymptomatic gene testing reveals the likelihood that a person will develop an inherited disease in the future. Understanding expectations allows for more complete assessment and counseling before presymptomatic gene testing for genetic diseases. Design: Descriptive qualitative. The population was people with a family history of HD. The sample was 17 asymptomatic adults with a positive family history of HD who requested presymptomatic gene identification atone tertiary genetic counseling program, 1995 to 1996. Methods: Semi-structured interviews concerning expectations of adults seeking presymptomatic genetic testing were conducted by telephone. Interviews occurred after the individuals had requested presymptomatic gene identification but before results were reported. Content analysis was used to identify the expectations and questions of those who had decided to seek presymptomatic testing. Findings: Common expectations included anticipating relief from uncertainty, hoping to plan for their future health care and life decisions, wanting to know if their children were at risk of developing HD, anticipating loss of family support from relatives, expecting relief from self monitoring, venturing into the unknown, and planning for disclosure. Participants attempted to avoid their loss of genetic privacy by withholding the decision to seek testing from their primary care providers. Conclusions: Participants seeking presymptomatic HD gene testing consider the effect of gene identification on themselves and their families. A desire to limit insurance or employment discrimination contributes to subjects not seeking input from health care providers in their decision making.

The Effect of a Translating Research into Practice (TRIP)-Cancer Intervention on Cancer Pain Management in Older Adults in Hospice

BACKGROUND Pain is a major concern for individuals with cancer, particularly older adults who make up the largest segment of individuals with cancer and who have some of the most unique pain challenges. One of the priorities of hospice is to provide a pain-free death, and while outcomes are better in hospice, patients still die with poorly controlled pain. OBJECTIVE This article reports on the results of a Translating Research into Practice intervention designed to promote the adoption of evidence-based pain practices for older adults with cancer in community-based hospices. SETTING   This Institutional Human Subjects Review Board-approved study was a cluster randomized controlled trial implemented in 16 Midwestern hospices. METHODS Retrospective medical records from newly admitted patients were used to determine the intervention effect. Additionally, survey and focus group data gathered from hospice staff at the completion of the intervention phase were analyzed. RESULTS Improvement on the Cancer Pain Practice Index, an overall composite outcome measure of evidence-based practices for the experimental sites, was not significantly greater than control sites. Decrease in patient pain severity from baseline to post-intervention in the experimental group was greater; however, the result was not statistically significant (P = 0.1032). CONCLUSIONS Findings indicate a number of factors that may impact implementation of multicomponent interventions, including unique characteristics and culture of the setting, the level of involvement with the change processes, competing priorities and confounding factors, and complexity of the innovation (practice change). Our results suggest that future study is needed on specific factors to target when implementing a community-based hospice intervention, including determining and measuring intervention fidelity prospectively.

The cancer pain practice index: a measure of evidence-based practice adherence for cancer pain management in older adults in hospice care.

Various clinical practice guidelines addressing pain assessment and management have been available for several years that pertain, at least to some extent, to older patients with cancer. Nonetheless, systematic evaluations or methodologically sound studies of adherence to pain management practice guidelines within Medicare-certified hospice programs are lacking. As part of a larger translating-research-into-practice pain improvement study involving older patients with cancer in hospice programs, we recognized the need to create a valid and reliable tool that can facilitate critical evaluation of hospice medical records for nurse and physician adherence to pain management guidelines to create a consolidated score for comparative and quality improvement purposes. We report the process used to create this tool, named the Cancer Pain Practice Index, and a guide to its use.

Implementing Evidence-Based Practices: Considerations for the Hospice Setting

With increased regulation and scrutiny of outcomes, hospice programs are being challenged to consider the implementation of evidence-based practices (EBPs). This study reports findings from hospice director interviews and staff focus groups, which occurred following the completion of a multifaceted translating research into practice (TRIP) intervention designed to promote evidence-based pain management practices. The purpose of this article is to provide background on the use of EBPs, to report facilitators and barriers to overall implementation of pain management EBPs in hospice, and to provide recommendations for hospices interested in increasing the use of EBPs. Three areas for evaluation prior to implementing an EBP initiative in hospices were identified: community, agency, and staff cultures. Recommendations for implementation of EBPs in hospices are provided.

Determining Community Provider Practices in Hospices: The Challenges of Documentation.

Documentation is a key factor in supporting consistency and quality of patient care in the hospice setting; however, variation among program provider practices, including documentation, was observed during the data collection phase of a study testing an intervention to promote Evidence-Based Practices for cancer pain management in 16 Midwestern hospices of varied size and structure. In the absence of uniformly adopted outcome measures and documentation standards, quality improvement initiatives in this important and growing healthcare sector will be difficult to manage. This article provides background on the importance of documentation, quality measures, outcomes of care, and regulatory imperatives in the hospice setting, with specific observations from our research study and suggestions for changes in documentation practices. From our observations, we posit the necessity of pertinent outcome measures supported by standardized documentation processes in hospice. Uniformity in key practice indicators and patient outcome measures in documentation systems would advance the movement to improve quality and consistency of care in hospices. Standardization of documentation systems and language would also facilitate the conduct of research in the hospice setting, a population for which advancing knowledge is essential to assure quality care at the end of life.

Geriatric pain competencies and knowledge assessment for nurses in long term care settings

Pain in older adults is a prevalent problem that affects quality of life and challenges nurses, particularly those caring for older adults living in long term care settings. Despite the national priority of pain management, insufficient knowledge of nurses about geriatric pain is a documented barrier to effective geriatric pain management in all long term care settings. To address this knowledge gap, a website (GeriatricPain.org) was developed by the National Geriatric Pain Collaborative with a grant from the MayDay Fund to provide a single site for evidenced-based, easy-to-use, downloadable resources on pain management. This paper describes the development of the most recent addition to the website, a set of evidence-based core geriatric pain management competencies and a geriatric pain knowledge assessment, and discusses their potential uses in improving pain care for older adults.