The role of information technology in translating educational interventions into practice: an analysis using the PRECEDE/PROCEED model.
Weir Charlene,McLeskey Nanci,Brunker Cherie,Brooks Denise,Supiano Mark A
Journal of the American Medical Informatics Association : JAMIA
OBJECTIVE:The evidence base for information technology (IT) has been criticized, especially with the current emphasis on translational science. The purpose of this paper is to present an analysis of the role of IT in the implementation of a geriatric education and quality improvement (QI) intervention. DESIGN:A mixed-method three-group comparative design was used. The PRECEDE/PROCEED implementation model was used to qualitatively identify key factors in the implementation process. These results were further explored in a quantitative analysis. METHOD:Thirty-three primary care clinics at three institutions (Intermountain Healthcare, VA Salt Lake City Health Care System, and University of Utah) participated. The program consisted of an onsite, didactic session, QI planning and 6 months of intense implementation support. RESULTS:Completion rate was 82% with an average improvement rate of 21%. Important predisposing factors for success included an established electronic record and a culture of quality. The reinforcing and enabling factors included free continuing medical education credits, feedback, IT access, and flexible support. The relationship between IT and QI emerged as a central factor. Quantitative analysis found significant differences between institutions for pre-post changes even after the number and category of implementation strategies had been controlled for. CONCLUSIONS:The analysis illustrates the complex dependence between IT interventions, institutional characteristics, and implementation practices. Access to IT tools and data by individual clinicians may be a key factor for the success of QI projects. Institutions vary widely in the degree of access to IT tools and support. This article suggests that more attention be paid to the QI and IT department relationship.
Effects of a self-management asthma educational program in Taiwan based on PRECEDE-PROCEED model for parents with asthmatic children.
Chiang Li-Chi,Huang Jing-Long,Yeh Kuo-Wei,Lu Chang-Ming
The Journal of asthma : official journal of the Association for the Care of Asthma
This study was conducted to evaluate the comparative effectiveness of two different asthma educational programs. One was self-management asthma education based on the PRECEDE-PROCEED model to change the influential factors based on a previous need assessment study in Taiwan. The other consisted of regular outpatient asthma education. The purposes were: 1) to compare differences in the asthma knowledge, self-efficacy, perceived effectiveness, children's cooperation, doctor-patient communication, and self-management behaviors in the experimental and control groups before education, and 2 weeks, 3 months, and 6 months after education; and 2) to compare differences in drug use, medication utilization, asthma severity, signs/symptoms of asthma, school absenteeism, and exercise ability before education, and 2 weeks, 3 months, and 6 months after education. Parents of asthmatic children were recruited from among outpatients of Chang Gung Children's Hospital, Taoyuan, Taiwan. They were grouped by registration number: those with even numbers were assigned to the experimental group, and those with odd numbers were assigned to the control group. Measurements were collected four times from all parents by means of a questionnaire and chart review. The General Linear Model: Repeat Measurement was used to compare variance differences. The following results were found. 1) Asthma knowledge, self-efficacy, perceived effectiveness, children's cooperation, and self-management behaviors significantly improved after the self-management asthma educational program based on PRECEDE-PROCEED. Except for perceived effectiveness, all variables still had good effectiveness after 6 months of follow-up. The experimental group was better than the control group in knowledge, children's cooperation, and self-management behaviors at the 3-month follow up, as well as in knowledge and children's cooperation at the 6-month follow-up. 2) In both the experimental and control groups, the educational program had a good impact on the health outcome. The average degree of drug use was reduced from 2.7 to 2.1. The number of visits was reduced from 4.75 to 3.55 per half year in the experimental group, and from 5.8 to 3.48 in the control group. The severity of asthma was reduced from 2.7 to 2.1. The signs/symptoms of asthma decreased, school absenteeism was reduced, and exercise ability improved after education at the 6-month follow-up in both groups. From the results of this study, the theory-based educational program had a good effect on self-management behaviors. From the repeat measurement analysis, we can understand the changing trend of the determinants, behaviors, and outcome indicators. The trend indicated that educational effects were sustained for at least 3 months, with some for 6 months. In order to maintain the educational effects, further specific series of educational programs can be designed based on the patterns of self-management behavior stages every 6 months. The effects of health outcomes may show significant differences using longer follow-up times in future clinical trials.
What is a planning model? An introduction to PRECEDE-PROCEED.
Crosby Richard,Noar Seth M
Journal of public health dentistry
Planning models exist at a macroscopic level; they serve as an organizing framework for an entire health promotion effort aimed at fostering reduction in a given disease. A particularly useful, widely applied, and easy-to-follow example of a planning model is the PRECEDE-PROCEED planning model (PPM). The PPM is very much an ecological approach to health promotion. The PPM is actually quite simple to understand once one realizes that it embodies two key aspects of intervention: a) planning, and (b) evaluation. The PPM guides the program planner to think logically about the desired end point and work "backwards" to achieve that goal. Through community participation, the planning process is broken down into objectives, step 3 sub-objectives, and step 4 sub-objectives. Conceptually, this approach to health promotion provides context to the use of theory, with theory being applied at the fourth step. This observation teaches a vital lesson, namely that program planning is larger and is a more comprehensive task compared to the subservient function of theory selection and application.
Effects of a PRECEDE-PROCEED model based ergonomic risk management programme to reduce musculoskeletal symptoms of ICU nurses.
Sezgin Duygu,Esin M Nihal
Intensive & critical care nursing
OBJECTIVES:To evaluate effects of a PRECEDE-PROCEED Model based, nurse-delivered Ergonomic Risk Management Program (ERMP) in the aim of reducing musculoskeletal symptoms of intensive care unit (ICU) nurses. METHODS:This pre-test post-test design for non-equivalent control groups study comprised 72 ICU nurses from two hospitals. A randomised sampling was done through the study population. The ERMP was delivered as an intervention including 26weeks of follow-up. Data was collected by "Descriptives of Nurses and Ergonomic Risk Reporting Form", "Rapid Upper Risk Assessment Form (RULA)", "ICU Environment Assessment Form" and "Personal interviews form". RESULTS:There was no difference between sociodemographic characteristics, work and general health conditions within intervention and control group. One month after the intervention, nurses had significant decrease in their total RULA scores during bending down and patient repositioning movements as 1.40 and 0.82, respectively. Six months after the ERMP, the mean total RULA scores of nurses during the patient repositioning was 4.39±1.49 which meant "immediate further analyses and modifications recommended". After all, pain intensity scores, medication use due to pain, and RULA ergonomic risk scores were significantly decreased, while exercise frequency was increased. CONCLUSIONS:The ERMP was effective to increase exercise frequency and to decrease musculoskeletal pain and ergonomic risk levels of ICU nurses.
Evidence-Based Strategies for the Prevention of Chronic Post-Intensive Care and Acute Care-Related Pain.
AACN advanced critical care
Chronic pain is prevalent in intensive care survivors and in patients who require acute care treatments. Many adverse consequences have been associated with chronic post-intensive care and acute care-related pain. Hence, interest in interventions to prevent these pain disorders has grown. To improve the understanding of the mechanisms of action of these interventions and their potential impacts, this article outlines the pathophysiology involved in the transition from acute to chronic pain, the epidemiology and consequences of chronic post-intensive care and acute care- related pain, and risk factors for the development of chronic pain. Pharmacological, nonpharmacological, and multimodal preventive interventions specific to the targeted populations and their levels of evidence are presented. Nursing implications for preventing chronic pain in patients receiving critical and acute care are also discussed.
The effectiveness of the Pain Resource Nurse Program to improve pain management in the hospital setting: A cluster randomized controlled trial.
Gunnarsdottir Sigridur,Zoëga Sigridur,Serlin Ronald C,Sveinsdottir Herdis,Hafsteinsdottir Elin Johanna Gudrun,Fridriksdottir Nanna,Gretarsdottir Elfa Tholl,Ward Sandra Evelyn
International journal of nursing studies
BACKGROUND:The Pain Resource Nurse program is a widely disseminated, evidence-based, nursing staff development program, designed to improve pain management in hospitals. The program has shown promising results, but has never been tested with a rigorous research design. OBJECTIVES:Our objective was to test the effectiveness of the Pain Resource Nurse program. Hypothesized outcomes included improvements in nurses' knowledge, attitudes, and assessment practices, and in patients' participation in decision-making, adequacy of pain management, pain severity, time spent in severe pain, pain interference, and satisfaction. DESIGN:Cluster randomized controlled trial. SETTING:A 650-bed university hospital in Iceland Participants: The sample consisted of a) patients ≥18 years of age, native speaking, hospitalized for at least 24h, alert and able to participate; and b) registered nurses who worked on the participating units. METHODS:Twenty three surgical and medical inpatient units were randomly assigned to the Pain Resource Nurse program (n=12) or to wait list control (n=11). The American Pain Society Outcome Questionnaire and the Knowledge and Attitudes Survey were used to collect data from patients and nurses respectively. Baseline data (T1) for patients were collected simultaneously on all units, followed by data collection from nurses. Then randomization took place, and the Pain Resource Nurse program was instituted. Ten months later, follow up (T2) data were collected, after which the nurses on the control group units received the Pain Resource Nurse program. RESULTS:At baseline, data were collected from 305 of the 396 eligible patients and at follow up from 326 of the 392 eligible patients, a 77% and 83% response rate respectively. At baseline, 232 of 479 eligible nurses responded and at follow-up 176 of the eligible 451 nurses responded, a 49% and 39% response rate, respectively. A nested mixed model analysis of covariance revealed that the intervention was successful in changing pain assessment practices, with pain assessment using standardized measures increasing from 13% to 25% in the intervention group while decreasing from 21% to 16% in the control group. None of the other hypothesized improvements were found. CONCLUSIONS:The Pain Resource Nurse program was successful in improving nurses' use of standardized measures for pain assessment. No effects were found on patient outcomes; pain was both prevalent and severe at both time points. Only minimal improvements were noted in response to this evidence-based staff development program. Changes in pain management practices remain a challenge in clinical settings.
Transcultural Pain Management: Theory, Practice, and Nurse-Client Partnerships.
Rosa William E
Pain management nursing : official journal of the American Society of Pain Management Nurses
Nursing is becoming increasingly aware of its impact as a global profession. Part of this evolution is the understanding that the Western evidence-based construct may not be reliably or universally applicable to transcultural settings and clients. In a global world, no 'one size fits all' and no singular approach to pain management is appropriate; there are, quite literally, infinite variations in cross-cultural dynamics. Nurses working in the field of pain management must be able to navigate their responsibilities within the global health context. The role of the pain management nurse in the global world is to provide individualized and culturally relevant pain management for clients, which is mindful of multifactorial contributors to the pain experience, such as the physiologic, affective, cognitive, behavioral, sociocultural, and environmental, and to view adequate pain management as an international human right. Through the skillful integration of theory, practice, and the ability to build respectful and responsible nurse-client partnerships, pain management nurses can deliver contextually relevant care that promotes safety, quality, and healing.
Evaluating the feasibility and effect of using a hospital-wide coordinated approach to introduce evidence-based changes for pain management.
Williams Anne M,Toye Christine,Deas Kathleen,Fairclough Denise,Curro Kathryn,Oldham Lynn
Pain management nursing : official journal of the American Society of Pain Management Nurses
This action research project explored the feasibility and effect of implementing a hospital-wide coordinated approach to improve the management of pain. The project used a previously developed model to introduce three evidence-based changes in pain management. Part of this model included the introduction of 30 pain resource nurses (PRNs) to act as clinical champions for pain at a local level. Both quantitative and qualitative measures were used to assess the feasibility and effect of the changes introduced. Quantitative data were gathered through a hospital-wide document review and assessment of the knowledge and attitude of the PRNs at two time points: time 1 before the introduction of the PRNs and time 2 near completion of the project (11 months later). A statistically significant improvement in the documentation of pain scores on admission and each nursing shift was apparent. However, no difference was found in the percentage of patients who had been prescribed opioids for regular pain relief that had also been prescribed and dispensed a laxative/aperient. Neither were any statistically significant decreases in patient pain scores observed. An assessment of the knowledge and attitudes of the PRNs showed an improvement from time 1 to time 2 that was statistically significant. The qualitative data revealed that despite the barriers encountered, the role was satisfying for the PRNs and valued by other hospital staff. Overall, the results revealed that the new model of change incorporating PRNs was a useful and effective method for introducing and sustaining evidence-based organizational change.
Music Therapy and Pain Management in Patients with End-Stage Liver Disease: An Evidence-Based Practice Quality Improvement Project.
Pathania Sonia,Slater Larry Z,Vose Courtney,Navarra Ann-Margaret
Pain management nursing : official journal of the American Society of Pain Management Nurses
BACKGROUND:Pain can negatively affect the inpatient hospitalization experience; however, in patients with compromised metabolic pathways who are more vulnerable to medication side effects, pain control becomes even more challenging. AIMS:This evidence-based practice quality improvement project explored the feasibility of implementing a music therapy intervention for improved pain management (pain intensity, analgesic volume) and patient satisfaction among patients with a diagnosis of cirrhotic end-stage liver disease in the acute care setting. DESIGN:The plan-do-check-act cycle served as the implementation framework. Four nurse champions were trained to implement a 30-minute music intervention. Self-selected musical selections were delivered via unit-based iPads with earbud headphones during 3 consecutive days. METHODS:Data collection was performed using unit-based measures for pain and patient satisfaction and an investigator-developed audit tool. Bivariate analyses and descriptive statistics were used to assess the effect of the intervention on the three outcomes of interest. RESULTS:Overall results from data collected with eight participants during a 6-week period indicated a 10% reduction in pain intensity and a 30% improvement in patient satisfaction with pain management care. CONCLUSIONS:Findings from this evidence-based practice quality improvement project provide support for the effectiveness of music therapy as an adjunct to traditional pharmacologic modalities for pain management of the end-stage liver disease patient population.
Evidence-based practice for pain management for cancer patients in an acute care setting.
Choi Mona,Kim Hee Sun,Chung Su Kyoung,Ahn Mee Jung,Yoo Jae Yong,Park Ok Sun,Woo So Rah,Kim So Sun,Kim Sun Ah,Oh Eui Geum
International journal of nursing practice
The purpose of this study is to implement an evidence utilization project using an audit and feedback approach to improve cancer pain management. A three-phased audit and feedback approach was used. A 46-bed oncology nursing unit in the university's cancer centre was selected as a research site. Nursing records extracted from 137 patients (65 for the baseline assessment and 72 for the follow-up audit) were used to examine nurse compliance with four audit criteria derived from best practice guidelines related to the assessment and management of pain. We observed a significant improvement in compliance from baseline to follow-up for the following criteria: documenting the side effects of opioids (2-83%), use of a formalized pain assessment tool (22-75%), and providing education for pain assessment and management to patients and caregivers (0-47%). The audit and feedback method was applicable to the implementation of clinical practice guidelines for cancer pain management. Leadership from both administrative personnel and staff nurses working together contributes to the spread of an evidence-based practice culture in clinical settings. As it was conducted in a single oncology nursing unit and was implemented over a short period of time, the results should be carefully interpreted.
Polish nurses' perceived barriers in using evidence-based practice in pain management.
Mędrzycka-Dąbrowska W,Dąbrowski S,Gutysz-Wojnicka A,Basiński A
International nursing review
AIM:The aim of this work was to present current practices, perceived barriers and perceived facilitators of Polish nurses in using EBP in the assessment and management of acute pain during the postoperative period in elderly patients. BACKGROUND:Advances in the study of pain and the methods for its relief since the late 1980s have led to a rise in the role of the nurse in pain management and monitoring. INTRODUCTION:The application of evidence-based practice associated with acute pain is on the increase in the world at large. METHODS:Eleven hospitals participated in this study. The project involved 1300 nurses working on surgical hospital wards. In this study, case study research and qualitative content analysis were used. The study was conducted using a dedicated questionnaire. RESULTS:Access to journals on evidence-based practice on the assessment and management of pain in elderly patients was assessed as less important by the respondents. Knowledge drawn from the media, scientific and medical journals was assessed by the respondents as unsatisfactory. The greatest barrier to nurses was the fact that scientific articles were published in English. CONCLUSION:Nurses' awareness of evidence-based practice increases with their education. Among the key problems are the lack of available professional publications in Polish literature, ignorance of English, shortage of time and lack of support from chief physicians of the ward. IMPLICATIONS FOR NURSING AND HEALTH POLICY:There is a need for the introduction of innovative strategies of teaching and approaches to the problem of evidence-based practice in approach to pain management in elder people among the Polish nurses. It is necessary to promote these issues in Polish scientific literature.
The Effectiveness of an Evidence-Based Pain Management Program on Pain Intensity and Chest Rehabilitation Improvement Among Chest Trauma Patients in a Thai Hospital.
Bilalee Sahas,Maneewat Khomapak,Sae-Sia Wipa,Nimmaanrat Sasikaan
Pain management nursing : official journal of the American Society of Pain Management Nurses
BACKGROUND:Pain after thoracic injury has further profound impacts on patients resulting in increased length of hospital stay and hospital care cost, and decreased quality of life. Utilization of the cutting-edge evidence on pain management that fits with the individual care context is therefore important. AIM:To examine the effects of an evidenced-based pain management program on the worst pain intensity and lung vital capacity among acutely ill hospitalized chest trauma patients. DESIGN:A two-group repeated measures design. SETTINGS:trauma unit, a university hospital in southern Thailand. PARTICIPANTS/SUBJECTS:42 chest trauma patients. METHODS:The study population included 42 chest trauma patients admitted to the trauma unit. Twenty-one eligible chest trauma patients were consecutively assigned into intervention and control groups. The impacts of the intervention on the level of the worst pain intensity and lung vital capacity were measured before implementation of the program and throughout the first 5 days of admission. RESULTS:The study found a significant reduction in the worst pain intensity and an increase in the lung vital capacity among chest trauma patients in the intervention group compared with the control group (p < .05). CONCLUSIONS:Use of a pain management program can be an effective, inexpensive, and low-risk intervention for the improvement of pain management and chest rehabilitation among chest trauma patients.
Sustainability of Evidence-Based Acute Pain Management Practices for Hospitalized Older Adults.
Shuman Clayton J,Xie Xian-Jin,Herr Keela A,Titler Marita G
Western journal of nursing research
Little is known regarding sustainability of evidence-based practices (EBPs) following implementation. This article reports sustainability of evidence-based acute pain management practices in hospitalized older adults following testing of a multifaceted Translating Research Into Practice (TRIP) implementation intervention. A cluster randomized trial with follow-up period was conducted in 12 Midwest U.S. hospitals (six experimental, six comparison). Use of evidence-based acute pain management practices and mean pain intensity were analyzed using generalized estimating equations across two time points (following implementation and 18 months later) to determine sustainability of TRIP intervention effects. Summative Index scores and six of seven practices were sustained. Experimental and comparison group differences for mean pain intensity over 72 hours following admission were sustained. Results revealed most evidence-based acute pain management practices were sustained for 18 months following implementation. Further work is needed to identify factors affecting sustainability of EBPs to guide development and testing of sustainability strategies.
Translating knowledge into best practice care bundles: a pragmatic strategy for EBP implementation via moving postprocedural pain management nursing guidelines into clinical practice.
Journal of clinical nursing
AIMS AND OBJECTIVES:To describe quantitative and qualitative best evidence as sources for practical interventions usable in daily care delivery in order to integrate best evidence into clinical decision-making at local practice settings. To illustrate the development, implementation and evaluation of a pain management nursing care bundle based on a clinical practice guideline via a real-world clinical exemplar. BACKGROUND:Successful implementation of evidence-based practice requires consistent integration of best evidence into daily clinical decision-making. Best evidence comprises high-quality knowledge summarised in systematic reviews and translated into guidelines. However, consistent integration of guidelines into care delivery remains challenging, partly due to guidelines not being in a usable form for daily practice or relevant for the local context. DESIGN:A position paper with a clinical exemplar of a nurse-led, evidence-based quality improvement project to design, implement and evaluate a pain management care bundle translated from a national nursing guideline. METHODS:A pragmatic approach to integrating guidelines into daily practice is presented. Best evidence from a national nursing guideline was translated into a pain management care bundle and integrated into daily practice in 15 medical-surgical (med-surg) units of nine hospitals of a large university hospital system in Finland. CONCLUSIONS:Translation of best evidence from guidelines into usable form as care bundles adapted to the local setting may increase implementation and uptake of guidelines and improve quality and consistency of care delivery. RELEVANCE TO CLINICAL PRACTICE:A pragmatic approach to translating a nursing guideline into a pain management care bundle to incorporate best evidence into daily practice may help achieve more consistent and equitable integration of guidelines into care delivery, and better quality of pain management and patient outcomes.
A theory-based hybrid II implementation intervention to improve pain management in Swiss nursing homes: A mixed-methods study protocol.
Brunkert Thekla,Ruppen Wilhelm,Simon Michael,Zúñiga Franziska
Journal of advanced nursing
AIM:To present a protocol for evaluating an implementation intervention to improve pain management in nursing homes by addressing behaviour change of the care workers. BACKGROUND:Pain management in nursing homes often is inadequate despite the availability of evidence-based pain management guidelines. Barriers to pain management in nursing homes occur on several levels including lack of knowledge and negative beliefs towards pain of care workers. A comprehensive approach incorporating contextual and behavioural factors is needed to sustainably improve pain management practice. DESIGN:A hybrid type II effectiveness-implementation design comprising an incomplete non-randomized stepped-wedge design and concurrent focus groups is proposed. METHODS:A convenience sample of six nursing homes will be included. Implementation of a facility pain management policy will be facilitated by introduction of a facility pain champion and training of all care workers in pain assessment and management. Quantitative outcomes assessed at baseline, after 3 and 6 months include self-efficacy in pain management and attitudes to pain of care workers and functional interference from pain and pain intensity in residents. Feasibility and acceptability of the intervention and implementation strategies and potential barriers to implementation will be explored in focus groups and interviews. (Protocol approved in October 2017). CONCLUSION:The proposed intervention implementation has been developed in a participatory approach involving relevant stakeholders. To further improve the contextual fit, development of implementation strategies was guided by the consolidated framework of implementation research. Findings of this research are expected to inform adaptions to the implementation of the intervention. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov: NCT03471390.
Structured approaches to pain management in the ICU.
Pasero Chris,Puntillo Kathleen,Li Denise,Mularski Richard A,Grap Mary Jo,Erstad Brian L,Varkey Basil,Gilbert Hugh C,Medina Justine,Sessler Curtis N
Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill.
Development of Process Control Methodology for Tracking the Quality and Safety of Pain, Agitation, and Sedation Management in Critical Care Units.
Walsh Timothy S,Kydonaki Kalliopi,Lee Robert J,Everingham Kirsty,Antonelli Jean,Harkness Ronald T,Cole Stephen,Quasim Tara,Ruddy James,McDougall Marcia,Davidson Alan,Rutherford John,Richards Jonathan,Weir Christopher J,
Critical care medicine
OBJECTIVE:To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. DESIGN:A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. SETTING:Eight Scottish ICUs over a 12-month period. PATIENTS:Mechanically ventilated patients. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman ρ = 0.75) and were reliable in clinician-clinician (weighted kappa; κ = 0.66) and clinician-researcher (κ = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale (ρ = 0.24) and was reliable in clinician-clinician (κ = 0.58) and clinician-researcher (κ = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale (ρ = 0.54), and reliability in clinician-clinician (κ = 0.29) and clinician-researcher (κ = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. CONCLUSIONS:Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time.
Initial assessment and management of pain: a pathway for care developed by the British Pain Society.
Price C,Lee J,Taylor A M,Baranowski A P,
British journal of anaesthesia
There is wide variation in how pain is managed in the UK. Patients often find themselves caught in a sea of referrals while continuing to suffer with poorly relieved symptoms. The British Pain Society's (BPS) Initial Assessment and Management of Pain care pathway (one of the five new BPS care pathways published by the Map of Medicine(®)) sets out how best to initially manage persistent pain. Patient education and supported self-management is recommended from an early stage. This pathway focuses on the start of the journey of a patient with pain, where a full diagnostic work-up is not yet complete. The pathway covers diverse recommendations such as appropriate content of a pain consultation, the use of clinical decision management tools to aid stratification of care, and resources to support patients to make informed decisions. Recommendations for monitoring of therapeutic effect are also included. Early identification of people at high risk of chronic disability may allow more intensive management, better use of resources, and reduction in disability. Implementation poses significant challenges; more research is needed to determine the most effective interventions. This article highlights practice points for the non-specialist, discusses areas of controversy, and examines the challenges of implementation.
Interdisciplinary chronic pain management: past, present, and future.
Gatchel Robert J,McGeary Donald D,McGeary Cindy A,Lippe Ben
The American psychologist
Chronic pain is a significant and costly problem in the United States as well as throughout the industrialized world. Unfortunately, there have been concerns about the effectiveness of traditional medical interventions, suggesting the need for alternative chronic pain treatment strategies. However, the introduction of the biopsychosocial model of pain during the past decade stimulated the development of more therapeutically effective and cost-effective interdisciplinary chronic pain management programs. In the present article we briefly review the history of pain management, discuss the major components of a "true" interdisciplinary pain management program, focus on the evidence-based outcomes that have documented the effectiveness of such interdisciplinary pain management programs, and note the barriers that have blocked the wider use of such programs. Finally, we discuss future directions in interdisciplinary pain management.
The effect of a lay-led, group-based self-management program for patients with chronic pain: a randomized controlled trial of the Danish version of the Chronic Pain Self-Management Programme.
Mehlsen Mimi,Hegaard Lea,Ørnbøl Eva,Jensen Jens Søndergaard,Fink Per,Frostholm Lisbeth
The Stanford Chronic Pain Self-Management Programme (CPSMP) consists of 6 2½-hour weekly workshops focusing on how to manage pain in daily life. The workshops are facilitated by 2 workshop leaders of whom at least 1 must suffer from a long-term pain condition. The program is highly structured and manualized. Only few controlled trials testing the effect of CPSMP exist. Enrolled in the study were 424 adults from 19 Danish municipalities, (72% women; age: 25-93 years) with pain of any etiology and great variation in pain history (0-50 yrs). Of these, 216 were randomized to a lay-led version of the CPSMP. The primary outcome was pain-related disability. Secondary outcomes were pain, pain catastrophizing, self-efficacy, emotional distress, physical symptoms, and illness worry. Outcomes were measured before randomization, immediately after the CPSMP (response rate: 94%), and at 3-month follow-up (response rate: 92%). National register data on health expenditure were obtained to examine effects on health care use. ClinicalTrials.gov Identifier: NCT01306747. The CPSMP had no effect on the primary outcome pain-related disability or on health expenditure during intervention and follow-up period. Small positive effects on emotional distress and illness worry 3 months after CPSMP were observed. Lay-led CPSMP is not recommended as treatment for chronic pain-related disability. This heterogeneous group of patients with pain did not benefit from the CPSMP except for a small, but clinically insignificant improvement in psychological well-being.
Ten Myths and Misconceptions Regarding Pain Management in the ICU.
Sigakis Matthew J G,Bittner Edward A
Critical care medicine
OBJECTIVES:The aim of this article is to expose common myths and misconceptions regarding pain assessment and management in critically ill patients that interfere with effective care. We comprehensively review the literature refuting these myths and misconceptions and describe evidence-based strategies for improving pain management in the ICU. DATA SOURCES:Current peer-reviewed academic journals, as well as standards and guidelines from professional societies. STUDY SELECTION:The most current evidence was selected for review based on the highest degree of supportive evidence. DATA EXTRACTION:Data were obtained via medical search databases, including OvidSP, and the National Library of Medicine's MEDLINE database via PubMed. DATA SYNTHESIS:After a comprehensive literature review, conclusions were drawn based on the strength of evidence and the most current understanding of pain management practices in ICU. CONCLUSIONS:Myths and misconceptions regarding management of pain in the ICU are prevalent. Review of current evidence refutes these myths and misconceptions and provides insights and recommendations to ensure best practices.
Web-based nursing intervention for self-management of pain after cardiac surgery: pilot randomized controlled trial.
Martorella Géraldine,Côté José,Racine Mélanie,Choinière Manon
Journal of medical Internet research
BACKGROUND:Most adults undergoing cardiac surgery suffer from moderate to severe pain for up to 6 days after surgery. Individual barriers and attitudes regarding pain and its relief make patients reluctant to report their pain and ask for analgesic medication, which results in inadequate pain management. More innovative educational interventions for postoperative pain relief are needed. We developed a Web-based nursing intervention to influence patient's involvement in postoperative pain management. The intervention (SOULAGE-TAVIE) includes a preoperative 30-minute Web-based session and 2 brief face-to-face postoperative booster sessions. The Web application generates reflective activities and tailored educational messages according to patients' beliefs and attitudes. The messages are transmitted through videos of a virtual nurse, animations, stories, and texts. OBJECTIVE:The aim of this single-blinded pilot randomized trial was to investigate the preliminary effects of a virtual nursing intervention (SOULAGE-TAVIE) to improve pain relief in patients undergoing cardiac surgery. METHODS:Participants (N = 60) were adults scheduled for their first cardiac surgery. They were randomly assigned to the experimental group using SOULAGE-TAVIE (n = 30) or the control group using usual care, including an educational pamphlet and postoperative follow-up (n = 30). Data were collected through questionnaires at the time of admission and from day 1 to day 7 after surgery with the help of a blinded research assistant. Outcomes were pain intensity, pain interference with daily activities, patients' pain barriers, tendency to catastrophize in face of pain, and analgesic consumption. RESULTS:The two groups were comparable at baseline across all demographic measures. Results revealed that patients in the experimental group did not experience less intense pain, but they reported significantly less pain interference when breathing/coughing (P = .04). A severe pain interference with breathing/coughing (pain ranked ≥ 7/10) was reported on day 3 after surgery by 15% of the patients in the experimental group (4/27), as compared to 44% (7/16) in the control group. On day 7 after surgery, participants in the experimental group also exhibited fewer pain-related barriers as measured by the Barriers Questionnaire-II (mean 10.6, SD 8.3) than patients in the control group (mean 15.8, SD 7.3, P = .02). No difference was found for pain catastrophizing. However, in both groups, means revealed a lower tendency to catastrophize pain before surgery as measured by the Pain Catastrophizing Scale (control group mean 1.04, SD 0.74; experimental group mean 1.10, SD 0.95) and after surgery (control group mean score 1.19, SD 0.94; experimental group mean score 1.08, SD 0.99). Finally, the experimental group consumed more opioid medication (mean 31.2 mg, SD 23.2) than the control group (mean 18.8 mg, SD 15.3, P = .001). CONCLUSIONS:This pilot study provides promising results to support the benefits of this new Web-tailored approach that can increase accessibility to health education and promote pain relief without generating more costs. TRIAL REGISTRATION:Clinicaltrials.gov NCT01084018; http://www.clinicaltrials.gov/ct2/show/NCT01084018 (Archived by WebCite® at http://www.webcitation.org/6CoTBkIoT).
Improvement of pain-related self-management for cancer patients through a modular transitional nursing intervention: a cluster-randomized multicenter trial.
Jahn Patrick,Kuss Oliver,Schmidt Heike,Bauer Alexander,Kitzmantel Maria,Jordan Karin,Krasemann Susann,Landenberger Margarete
Patients' self-management skills are affected by their knowledge, activities, and attitudes toward pain management. This trial aimed to test the Self Care Improvement through Oncology Nursing (SCION)-PAIN program, a multimodular structured intervention to reduce patients' barriers to self-management of cancer pain. Two hundred sixty-three patients with diagnosed malignancy, pain>3 days, and average pain > or = 3/10 participated in a cluster-randomized trial on 18 wards in 2 German university hospitals. Patients on the intervention wards received, in addition to standard pain treatment, the SCION-PAIN program consisting of 3 modules: pharmacologic, nonpharmacologic pain management, and discharge management. The intervention was conducted by specially trained cancer nurses and included components of patient education, skills training, and counseling. Starting with admission, patients received booster sessions every third day and one follow-up telephone counseling session within 2 to 3 days after discharge. Patients in the control group received standard care. Primary end point was the group difference in patient-related barriers to self-management of cancer pain (Barriers Questionnaire-BQ II) 7 days after discharge. The SCION-PAIN program resulted in a significant reduction of patient-related barriers to pain management 1 week after discharge from the hospital: mean difference on BQ II was -0.49 points (95% confidence interval -0.87 points to -0.12 points; P=0.02). Furthermore, patients showed improved adherence to pain medication; odds ratio 8.58 (95% confidence interval 1.66-44.40; P=0.02). A post hoc analysis indicated reduced average and worst pain intensity as well as improved quality of life. This trial reveals the positive impact of a nursing intervention to improve patients' self-management of cancer pain.
Senior nursing students' clinical judgments in pain management.
Samuels Joanne G,Leveille Deborah M
Sustained improvement in pain management depends on new nurses entering the healthcare system with strong practice knowledge and competent clinical judgment. The recent call to revamp nursing education to meet practice realities recommended integrating classroom and clinical teaching using a variety of pedagogies to develop students' clinical judgment skills. Understanding the pain management clinical judgments occurring in practice helps to methodically construct meaningful teaching interventions and guide faculty support of students. The authors discuss their study, and its outcomes, related to the pain management clinical judgments of senior students.
Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions.
Kaye Alan D,Helander Erik M,Vadivelu Nalini,Lumermann Leandro,Suchy Thomas,Rose Margaret,Urman Richard D
Pain and therapy
The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician's role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.
Feasibility of Imported Self-Management Program for Elderly People with Chronic Pain: A Single-Arm Confirmatory Trial.
Ikemoto Tatsunori,Shiro Yukiko,Ikemoto Kayo,Hayashi Kazuhiro,Arai Young-Chang,Deie Masataka,Beeston Lee,Wood Bradley,Nicholas Michael
Pain and therapy
INTRODUCTION:Multidisciplinary pain management programs incorporating a cognitive-behavioral therapy (CBT) approach have been reported to be helpful for elderly people with chronic pain. However, it is unclear whether the same program for elderly people with chronic pain would translate to different cultures. This study investigated whether a multidisciplinary program based on that of Nicholas et al. (Pain 154(6):824-835, 2013) in Australia would be effective for elderly people with chronic pain in Japan. METHODS:Twenty-seven community-dwelling elderly people with chronic pain were enrolled to confirm changes (effect size d = 0.5) in pain disability, which were previously reported by Nicholas et al. The multidisciplinary program consisted of eight sessions (2 sessions a week for 4 weeks). Pain disability was assessed using the Pain Disability Assessment Scale (PDAS) as the primary outcome at the baseline, the beginning and the end of the program, and the 1- and 3-month (final) follow-up. We also assessed the pain severity, catastrophizing, pain self-efficacy, and physical function with the Timed Up and Go test (TUG) and the two-step test as secondary outcomes. RESULTS:PDAS, pain catastrophizing, and pain self-efficacy were significantly improved immediately after the program compared with baseline, and these effects were maintained at 3-month follow-up. The effect size (d) for the PDAS score was a medium size (0.54) from baseline to 3-month follow-up. Those who showed improvements in TUG immediately after the program tended to report improved psychometric measures at 3-month follow-up. CONCLUSION:These results suggest that the Japanese multidisciplinary program has a similar effect on pain disability as that reported by Nicholas et al. This finding has important implications for the development of pain services in community-dwelling elderly Japanese.
Lessons for Better Pain Management in the Future: Learning from the Past.
Manchikanti Laxmaiah,Singh Vanila,Kaye Alan D,Hirsch Joshua A
Pain and therapy
The treatment of noncancer pain in the United States and globally is met with significant challenges, resulting in profound physical, emotional, and societal costs. Based on this need, numerous modalities have been proposed to manage chronic pain, including opioid and nonopioid interventions as well as surgical approaches. Thus, the future of pain management continues to be mired in evolving concepts and constant debates. Consequently, it is crucial to understand the past as we move towards the future. The evolution of lessons for better pain management at present and for the future starting from the 1990s to the present date are reviewed and emphasized with a focus on learning from the past for the future. This review summarizes the evolution of multiple modalities of treatments, including multidisciplinary programs, multimodal therapy, interventional techniques, opioid therapy, other conservative modalities, and surgical interventions. This review emphasizes the individual, patient-centered development of an effective pain treatment plan after proper evaluation to establish a diagnosis. It includes measurable outcomes that focus on improvements in the quality of life and activities of daily living, as well as improvement in pain and function and, most importantly, return to productive citizenship. It is crucial that the knowledge of best practices be advanced, along with emphasis on lessons learned in the past to provide best practices for better pain management.
UC Davis Train-the-Trainer Primary Care Pain Management Fellowship: Addressing the Pain Management Education Gap.
Fishman Scott M,Copenhaver David,Lorenzen Kathryn,Schlingmann Ellery,Chung Christy
Academic medicine : journal of the Association of American Medical Colleges
PROBLEM:Primary care providers are responsible for the majority of pain care and opioid prescribing, but they are often inadequately trained. Training current providers to address the crisis of excessive opioid prescribing and inadequate pain management is a substantial workforce problem that requires urgent action. This educational need is vast and requires a staged solution to amplify its effect. APPROACH:The University of California Davis Train-the-Trainer (T3) Primary Care Pain Management Fellowship targets the most pressing topics related to pain management, including prescription drug abuse, responsible opioid prescribing, and substance abuse, as well as broad coverage of comprehensive pain management. It offers an innovative, scalable solution to address the education gap in pain management that, in part, fuels the opioid epidemic in the United States. The T3 Fellowship incorporates a competency-based curriculum and a hybrid educational model of in-person and distance-based learning and direct faculty-fellow mentoring to comprehensively train primary care providers in pain care and prepare them to train others. Since it was established in 2017, 2 cohorts (of 17 and 26 fellows, respectively) have completed the 10-month fellowship and a third cohort of 38 fellows started the program in September 2019. OUTCOMES:Pre- and post-program surveys for the first 2 cohorts, and a 6-month post-program survey for the first cohort, demonstrated fellows' improvement and sustained performance in pain competencies as well as increased recognition and understanding of pain and related topics. NEXT STEPS:If adopted by other institutions and expanded across the country, the T3 Fellowship holds potential for developing an ever-growing legion of trained professionals who will locally fill the need for effective pain management, including appropriate opioid prescribing. Advancing this model will require further economic and feasibility studies to assess costs, resources, and other variables, as well as a robust comprehensive outcomes program.
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.
Devlin John W,Skrobik Yoanna,Gélinas Céline,Needham Dale M,Slooter Arjen J C,Pandharipande Pratik P,Watson Paula L,Weinhouse Gerald L,Nunnally Mark E,Rochwerg Bram,Balas Michele C,van den Boogaard Mark,Bosma Karen J,Brummel Nathaniel E,Chanques Gerald,Denehy Linda,Drouot Xavier,Fraser Gilles L,Harris Jocelyn E,Joffe Aaron M,Kho Michelle E,Kress John P,Lanphere Julie A,McKinley Sharon,Neufeld Karin J,Pisani Margaret A,Payen Jean-Francois,Pun Brenda T,Puntillo Kathleen A,Riker Richard R,Robinson Bryce R H,Shehabi Yahya,Szumita Paul M,Winkelman Chris,Centofanti John E,Price Carrie,Nikayin Sina,Misak Cheryl J,Flood Pamela D,Kiedrowski Ken,Alhazzani Waleed
Critical care medicine
OBJECTIVE:To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN:Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS:Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS:The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS:We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
Clinical Practice Guidelines and Consensus Statements About Pain Management in Critically Ill End-of-Life Patients: A Systematic Review.
Durán-Crane Alejandro,Laserna Andrés,López-Olivo María A,Cuenca John A,Díaz Diana Paola,Cardenas Yenny Rocío,Urso Catherine,O'Connell Keara,Azimpoor Kian,Fowler Clara,Price Kristen J,Sprung Charles L,Nates Joseph L
Critical care medicine
OBJECTIVES:To identify and synthesize available recommendations from scientific societies and experts on pain management at the end-of-life in the ICU. DATA SOURCES:We conducted a systematic review of PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and Biblioteca Virtual en Salud from their inception until March 28, 2019. STUDY SELECTION:We included all clinical practice guidelines, consensus statements, and benchmarks for quality. DATA EXTRACTION:Study selection, methodological quality, and data extraction were performed independently by two investigators. A quality assessment was performed by four investigators using the Appraisal of Guidelines for Research and Evaluation II instrument. The recommendations were then synthesized and categorized. DATA SYNTHESIS:Ten publications were included. The Appraisal of Guidelines for Research and Evaluation II statement showed low scores in various quality domains, especially in the applicability and rigor of development. Most documents were in agreement on five topics: 1) using a quantitative tool for pain assessment; 2) administering narcotics for pain relief and benzodiazepines for anxiety relief; 3) against prescribing neuromuscular blockers during withdrawal of life support to assess pain; 4) endorsing the use of high doses of opioids and sedatives for pain control, regardless of the risk that they will hasten death; and 5) using quality indicators to improve pain management during end-of-life in the ICU. CONCLUSIONS:In spite of the lack of high-quality evidence, recommendations for pain management at the end-of-life in the ICU are homogeneous and are justified by ethical principles and agreement among experts. Considering the growing demand for the involvement of palliative care teams in the management of the dying patients in the ICU, there is a need to clearly define their early involvement and to further develop comprehensive evidence-based pain management strategies. Based on the study findings, we propose a management algorithm to improve the overall care of dying critically ill patients.
Impact of audit and feedback with action implementation toolbox on improving ICU pain management: cluster-randomised controlled trial.
Roos-Blom Marie-José,Gude Wouter T,de Jonge Evert,Spijkstra Jan Jaap,van der Veer Sabine N,Peek Niels,Dongelmans Dave A,de Keizer Nicolette F
BMJ quality & safety
BACKGROUND:Audit and feedback (A&F) enjoys widespread use, but often achieves only marginal improvements in care. Providing recipients of A&F with suggested actions to overcome barriers (action implementation toolbox) may increase effectiveness. OBJECTIVE:To assess the impact of adding an action implementation toolbox to an electronic A&F intervention targeting quality of pain management in intensive care units (ICUs). TRIAL DESIGN:Two-armed cluster-randomised controlled trial. Randomisation was computer generated, with allocation concealment by a researcher, unaffiliated with the study. Investigators were not blinded to the group assignment of an ICU. PARTICIPANTS:Twenty-one Dutch ICUs and patients eligible for pain measurement. INTERVENTIONS:Feedback-only versus feedback with action implementation toolbox. OUTCOME:Proportion of patient-shift observations where pain management was adequate; composed by two process (measuring pain at least once per patient in each shift; re-measuring unacceptable pain scores within 1 hour) and two outcome indicators (acceptable pain scores; unacceptable pain scores normalised within 1 hour). RESULTS:21 ICUs ( n=11; n=10) with a total of 253 530 patient-shift observations were analysed. We found absolute improvement on adequate pain management in the group (14.8%; 95% CI 14.0% to 15.5%) and the group (4.8%; 95% CI 4.2% to 5.5%). Improvement was limited to the two process indicators. The group achieved larger effects than the group both on the composite adequate pain management (p<0.05) and on measuring pain each shift (p<0.001). No important adverse effects have occurred. CONCLUSION:Feedback with toolbox improved the number of shifts where patients received adequate pain management compared with feedback alone, but only in process and not outcome indicators. TRIAL REGISTRATION NUMBER:NCT02922101.