Sunday, August 31, 2008

Simulating pain crisis

There is an interesting pair of studies in Quality Management in Health Care on the use of a simple Microsoft Excel-based simulation tool for teaching medical residents to manage pain crisis in cancer inpatients. The authors had previously determined through surveys of residents and nurses that residents were unprepared for and uncomfortable with managing pain with opioids. Specifically, they were afraid of respiratory depression, especially with escalating doses and long-acting opioids, and had no preparation for converting to other routes or drugs. The informal practice was to manage all cancer pain with intermittent short-acting opioids. The result was that patients complained of uneven pain control marked by "peaks & valleys" and that average pain scores actually increased among hospitalized cancer patients. Not surprisingly, patients, residents and nurses were dissatisfied with pain management. Outcomes, by the way, were unchanged following standard educational interventions such as grand rounds presentations.

The authors then developed a "case-based Microsoft Excel program with an interface from which the user selects from a list of medications, orders a dose, and chooses a follow-up interval to assess pain response." Cases are based on 15 actual patients who had been admitted for treatment of pain exacerbation. All opioids, doses, and times given, and pain score responses for these patients were entered. I'm unclear as to what happened next [I'm not a math or computer guy]. Noting that "patients did not respond the same to any given dose of narcotic" [the grinding teeth you hear are mine] they somehow, using a variety of sources, derived a range of "sensitivities of response to equivalent morphine doses." Operationally, they applied a random number generator to select a sensitivity to each starting dose applied to each patient. One hundred sensitivities are possible. Applied to the 15 patients, this translates to 1500 different cases.

The interface provides a dose-response curve that shows the user what happened when a dose was administered in a particular case. If the user chooses a reassessment interval that is too long, the graph may trend back up into higher pain scores.
The graph above shows one possible dose-response curve for a single dose of opioid. As the case develops, the curve reflects response to all doses over time (48 hours in this study).
Principles of care taught didactically, then reinforced by simulator (Goal: rapid induction of pain relief):
  • morphine is the default opioid (ok, so I translated the archaic "narcotic" to the preferred modern term)
  • do not define a specific starting dose; instead, assess, start low, rapidly titrate using early close follow up to each dose
  • use standard conversion table
  • reassess every 30 - 60 minutes during titration
  • convert to long-acting opioid as soon as possible ("early in care") to stabilize pain and medication regimen
  • use 8-hour intervals for long-acting agents
I won't go into the details, but they tested the simulator against seven actual patients admitted solely for pain control and found that the pre-determined dose-responses programmed into the simulator included those exhibited by the patients. In a pilot study 31 residents completed 2-3 simulations. Results were independently evaluated by 7 reviewers. The finding was that 90% of the residents improved their pain care.
A follow up study (the 2nd article) of several small groups of residents entering their oncology rotation showed that, after simulator training, pain scores--of actual patients they cared for on the oncology unit--decreased (over the first 48 hours after admission for pain control), more patients were prescribed long acting agents, and less naloxone was used.
We have known for many years that providing information alone, and that teaching skills such as safe opioid conversion, does not translate into improved pain control. Even a standard case-based approach is not "real" enough for clinicians to apply the critical thinking and get the feedback they need in order to overcome the endemic fear these drugs evoke. The approach these articles describe is a relatively simple, relatively inexpensive intervention that allows barriers to be broken down in a safe environment.
It wasn't always clear when the authors were describing intravenous vs oral medication administration. But if the reassessment interval for intravenous and oral opioids was the same (30-60 minutes), the patient receiving the intravenous medication is potentially left in unnecessary pain long after the peak effectiveness could have been assessed. In the first article the authors stated that nurses and residents are the primary care providers for patients on the oncology unit. There was no description of the clinical role that nurses played in the care of patients in pain. It is pretty clear to most of us that "the team" needs to include the bedside nurse. The early reassessment of intravenous opioid administration is surely part of the nursing role.

1. Harting B, Hasler S, Abrams R, Odwazny R, McNutt R. Computer-based simulation as a teaching tool for residents treating patients with cancer-related pain crises. Qual Manag Health Care. 2008 Jul-Sep;17(3):192-9.
2. Harting B, Abrams R, Hasler S, Odwazny R, McNutt R. Effects of training on a simulator of pain care on the quality of pain care for patients with cancer-related pain. Qual Manag Health Care. 2008 Jul-Sep;17(3):200-3.

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