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Southern California CSU DNP Consortium Southern California CSU DNP Consortium California State University, Fullerton California State University, Long Beach California State University, Los Angeles USING COMFORT MENU TO IMPACT PAIN EXPERIENCE A DOCTORAL PROJECT Submitted in Partial Fulfillment of the Requirements For the degree of DOCTOR OF NURSING PRACTICE By Chona Melvin Doctoral Project Committee Approval: Ahlam Jadalla, PhD, RN, Team Leader Joy R Goebel, PhD, RN, FPCN Team Member May 2019 Copyright Chona Melvin 2019 ii ABSTRACT A quality improvement (QI) project of a comfort menu of nonpharmacological interventions (NPIs) was implemented at a spine surgical unit. The purpose of this QI project was to improve patients’ pain experience as measured by pain indicators and length of stay (LOS) in postsurgical spine patients through the development, implementation, and evaluation of a comfort menu of NPIs. The comfort menu consisted of 6 NPIs (acupuncture, pet therapy, hot/cold therapy, virtual reality, music therapy, and reiki/meditation) that are available in the spine surgical unit. Baseline data came from 32 patients who did not utilize NPIs and postimplementation data came from 71 patients who utilized NPIs. Post-comfort-menu implementation showed that the most frequently used NPI was hot/cold therapy (66 out of 71 patients; 92.95%). The aggregate mean Numerical Rating Scale (NRS) pain level decreased from 7 out of 10 (baseline sample) to 6 out of 10 (postimplementation sample), which was a percent change decrease of 14.3%. The aggregate mean net Morphine Equivalent Daily Dose (MEDDn) decreased from 78.10 mg/day (baseline sample) to 48.53 mg/day (postimplementation sample), which was a percent change decrease of 37.9%. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) pain satisfaction score increased from 71.1% (baseline sample) to 100% (postimplementation sample), which was a percent change increase of 40.6%. Finally, the LOS decreased from 6.56 days (baseline sample) to 3.67 days (postimplementation sample), which was a percent change decrease of iii 44.1%. The implementation of the comfort menu not only improved spinal surgery patients’ pain experience, it also conformed to The Joint Commission’s 2018 revised pain management requirements. By providing patients tools to reduce their pain and by including them in choosing the type of nonpharmacological pain management treatments, patients may feel more empowered to utilize these NPIs to reduce their pain beyond their hospital stay. iv TABLE OF CONTENTS ABSTRACT ................................................................................................................... iii LIST OF TABLES ......................................................................................................... viii LIST OF FIGURES ....................................................................................................... ix ACKNOWLEDGMENTS ............................................................................................. x BACKGROUND ........................................................................................................... 1 Problem Statement ................................................................................................ 1 Local Context ........................................................................................................ 1 Purpose Statement................................................................................................. 2 Conceptual Framework ......................................................................................... 2 Lewin’s Change Theory ................................................................................. 3 Model for Improvement with a PDSA Cycle ................................................ 4 REVIEW OF THE LITERATURE ............................................................................... 8 Search Strategies ................................................................................................... 8 Managing Pain in Postsurgical Spine Patients ...................................................... 9 Use of NPIs to Manage Postsurgical Spine Pain .................................................. 10 Acupuncture ................................................................................................... 11 Mind-Body Therapy ...................................................................................... 12 Music Therapy ............................................................................................... 13 Hot/Cold Therapy .......................................................................................... 14 Animal-based/Pet Therapy ............................................................................ 15 Virtual Reality ................................................................................................ 16 Comfort Menu of NPIs ......................................................................................... 17 METHODS .................................................................................................................... 19 Design ................................................................................................................... 19 Preliminary Work ................................................................................................. 19 Setting ................................................................................................................... 20 Participants............................................................................................................ 20 Ethical Issues ........................................................................................................ 20 Procedures ............................................................................................................. 21 v Planning ......................................................................................................... 21 Preimplementation ......................................................................................... 22 Implementation .............................................................................................. 22 Postimplementation ....................................................................................... 23 Measurement tools ................................................................................................ 24 NRS Pain Level ............................................................................................. 24 MEDD ............................................................................................................ 25 Hospital LOS ................................................................................................. 25 HCAHPS Pain Satisfaction Score.................................................................. 26 Data Analysis ........................................................................................................ 26 NRS Pain Level ............................................................................................. 27 MEDDn .......................................................................................................... 27 LOS and HCAHPS Pain Satisfaction Score .................................................. 27 RESULTS: PROJECT MANUSCRIPT ........................................................................ 28 DISCUSSION ................................................................................................................ 29 Overview ............................................................................................................... 29 Limitations ............................................................................................................ 31 Conclusion ............................................................................................................ 31 REFERENCES .............................................................................................................. 33 APPENDIX A: PLAN-DO-STUDY-ACT MODEL ................................................... 44 APPENDIX B: TABLE OF EVIDENCE.................................................................... 45 APPENDIX C: CSULB IRB APPROVAL ................................................................. 65 APPENDIX D: CSMC IRB APPROVAL ................................................................... 66 APPENDIX E: COMFORT MENU FOR PATIENTS ............................................... 67 APPENDIX F: COMFORT MENU GUIDE FOR NURSING STAFF ..................... 68 APPENDIX G: CSMC CLEARANCE TO DISSEMINATE AND PUBLISH .......... 69 APPENDIX H: DATA EXTRACTION TOOL .......................................................... 70 APPENDIX I: PRIMARY OUTCOME EXTRACTION TOOL .............................. 71 APPENDIX J: MORPHINE EQUIVALENT DAILY DOSE CALCULATION ...... 72 APPENDIX K: POSTIMPLEMENTATION SURVEY QUESTIONNAIRES FOR NURSING STAFF ......................................................................................................... 73 vi APPENDIX L: EQUIANALGESIC CHART ............................................................. 74 APPENDIX M: MANUSCRIPT SUBMITTED TO The Joint Commission Journal on Quality and Patient Safety ........................................................................................ 75 vii LIST OF TABLES Table Page 1. Sample Demographics ......................................................................................... 80 2. Baseline and Postimplementation Outcome
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