Impacting Patient Satisfaction in Pediatric Pain Management April 12, 2015

Jeffrey Suzewits, DO, MPH, FAAFP Chief Medical Information Officer Central Illinois Division Hospital Sisters Health System

Rebecca Howard, RN, BSN, Pediatric Educator HSHS St. John’s Children’s Hospital

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS. Conflict of Interest

Jeffrey Suzewits, DO, MPH, FAAFP Rebecca Howard, RN, BSN

Out of full disclosure, registration fees and accommodations are being covered by GetWellNetwork. However, this will not impact the speakers ability to present an unbiased presentation.

• Identify the impact that Interactive Patient Care™ (IPC) technology has on key hospital metrics such as pain management and overall patient satisfaction.

• Evaluate how an innovative IPC approach educates, engages and activates patients and their families in the care experience, thereby impacting population health initiatives.

• Assess actual results and clinical and operational outcomes to determine how an IPC strategy can streamline the patient pain assessment process, facilitate clinical workflows and improve patient care.

• Explain how to integrate various health IT systems -- pharmacy dispensing, nursing phones, patient education and the EMR -- into a single platform that facilitates pain management and understanding, documents pain assessments and streamlines workflows.

Value

Patient satisfaction scores surrounding pain management initially increased by 68 percent

Automated pain assessments, documentation and notifications created efficiencies for nursing staff, helping them prioritize which patients to follow up with based on their pain rating

Integrating the IPC system with the hospital’s EMR and nursing text messaging service helped streamline assessments and automate documentation, saving nurses valuable time and enabling them to quickly prioritize patient follow-up

With the new pain management process in place, St. John’s tracked more than 9,500 patient responses through GetWellNetwork, and saw a 10 percent increase in patients that rated their pain below 4 on a scale of 0 to 10

St. John’s increased patient satisfaction scores for pain control by 68 percent, and decreased pain scores by frequent, timely reassessment Who Are We?

We are St. John’s Children’s Hospital

• Located in Springfield, Illinois – state capitol

• Children’s and women’s hospital-within-a-hospital – part of Hospital Sisters Health System

• Teaching hospital affiliated with SIU School of Medicine

• Serve a geographically disparate region (rural)

• The only children’s hospital in south-central Illinois About Us • Level I Trauma and Level 2 Pediatric Trauma, Level III NICU, Regional Perinatal Center, Regional Pediatric Critical Care Center

• Dedicated Pediatric/NICU/Maternal ground and air transport teams

• 85 licensed Pediatric/NICU beds

• 40 licensed LDRP beds (includes antenatal)

• Pediatric Day Hospital/Sedation Program

• Comprehensive Pediatric Rehabilitation Program

Our Story

• Began with a focus on entertainment

• Lean process improvement event that included keeping up with lost videos and games

• Team researched entertainment systems

Concurrent Story Transition to electronic medical records (EMR) had an impact on: - Nursing workflow - Time management - Focus more on computer, less at bedside - Tremendous learning curve

Opportunities to Expand and Improve Care

• Lean event and move to EMR revealed opportunity to expand project scope and look at new opportunities to provide excellent care

• Widened product search to find one solution that also offers education to the patient and family

• Outcome: An interactive patient care system that provides patient engagement, standardized education, customer service, and nursing efficiencies, as well as entertainment!

Solution

• Implemented in December 2011 through internal grant funding

• Interactive patient care systems use the bedside TV, mobile devices and computers to engage patients and their families in their health care

• Patients have a range of personalized tools that include robust education, communication/internet features and entertainment, plus the ability to provide input on the patient and family experience

• Enables the patient and family to stay connected during their stay Focus Change

• Press-Ganey survey results from previous data helped us recognize the need for a change in focus – project scope widened to incorporate pain management and improve communication

• Research supports and extends studies measuring pediatric pain through the interactive use of face scales (Gulur, et. Al, 2009 and Cravero, et. Al, 2013)

• Studies show that parent or child satisfaction increases with the standardization of pain assessment, and that children want better communication around pain with their nurse (Habich, et. Al, 212)

Why • Pain management solution improves efficiency of bedside clinician

• Leveraging technology helps manage pain control, and streamlines assessments and documentation through integration of HIT systems

• Advantages include:

 Standardized, consistent user-friendly method of assessing pain  Allows for real-time data collection and limits recall bias (Stinson, 2009)  No interference of clinician presence  Direct transfer of data decreases need for extra resources (Gulur, et. Al, 2009) Initial Barriers • Technology changes

• Resources

• Nurse comfort level, engagement in new process

• Pre-existing pain management barriers in pediatric patients.  Narcotic concerns  Beliefs in children’s expression of pain Parents’ and nurses’ perceptions of pain should only be considered as estimates rather than expressions of the pain experienced, and not the same as children’s self-reports (Zhou, H, et. Al, 2008) Roll Out

KEY: Include nursing staff in discussions of managing pain differently

Training to comprise: - Technology devices - Concept of interactive patient care - Automated documentation - Understanding a new process with a focus on pain management

Phase 1: How It Works

The nurse removes a pain medication from the medication dispensing system and the pathway is triggered

Pain characteristics should be reassessed within 30-60 minutes after each intervention (Habich, et al, 2012)

45 minutes after the medication removal, the patient is sent a pain rating question from our interactive patient care system

How It Works

At this time, the patient is offered more education or relaxation choices How It Works

The result of the pain reassessment then goes into the EMR for documentation

Upon reassessment, the goal is to achieve a pain score of less than 4 or a report of pain management satisfaction (Habich, et. Al, 2012) How It Works

Simultaneously, the result of the pain reassessment is sent to the RN caring for the patient Integration At-a-Glance

IPC System Pain Management Pathway Pain Medication Withdrawal Meditech

Automated EMR EMR Documentation

Pain Assessment (Prompt over TV)

Nurse Notification

Automated Nursing Notification Success Stories

New ability for nurses to reprioritize care

Positive family feedback

Improving patient experience data Special Patient

Were you surprised to see messages come to you on your television? Mary: I was surprised! Parents: I (Dad) was not. I (Mom) was surprised and thought it was a neat system – plenty easy for even little kids to understand.

What did you like about being able to rate your pain on your television? Mary: I liked the faces. Parents: We could tell the nurses how Mary felt.

Was it difficult to do (rate your pain)? Mary: No

Mary’s Story

Do you think it helped you get better? Mary: Yes. Parents: We think so. The nurses quickly responded and modified Mary’s pain medicine according to our response, and not being in a lot of pain helped her to rest and get better faster.

Anything else that you would like to say? Mary: I liked the movies. I loved the nurses and doctors. I also liked the puzzle and game room and all of the presents from people coming to visit me! Expansion

• Initial pain management focus had only been on reassessment of pain

• The (initial) assessment may reveal unrealistic expectations for pain management that, when addressed early in the plan of care, can minimize misconceptions and improve patient outcomes (Habich, Michele, et. Al, 2012)

• Decision made to expand assessment of pain and education about management to the time of admission

Phase 2: How It Works

Prior to the patient and family gaining access to the television, the following question is prompted

Parents are encouraged to respond for small children

How It Works

The “yes” response is sent to the phone of the RN caring for the patient

How It Works

The patient and/or family are directed to the education page regarding options of managing pain while in the hospital How It Works

The patient and family are informed about our pain assessment plan and their health care team while becoming familiar with using the television to participate in their plan of care Pain Re-assessment Data 2012-2014: 9,759 pain reassessment responses from patients! September 2012-December 2012 • 76 percent of patients rated their pain at a 4 or less

January 2013-December 2013 • 78 percent of patients rated their pain at a 4 or less

January 2014-December 2014 • 86 percent of patients rated their pain at a 4 or less Pain Assessment Admission Data

1,757 responses from April 2014 to December 2014

Assessment includes:

• Notification of nurse • Education regarding pain management • Relaxation/comfort techniques How Well Pain is Controlled (Mean Score) 92

84 Mean Score Linear (Mean Score) 82

78 *2 Quarters missing data due to Pediatric HCAHPS trial 76 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014 2014 2014

Phase Phase I II How Well Pain is Controlled (Top Box %) 80

How Well Pain Controlled (Top Box %) 40

Linear (How Well Pain Controlled (Top 30 Box %))

0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014 2014 2014

Phase Phase I II Results

Increased patient satisfaction around pain management and communication through use of standard assessment and education tools

Added an electronic process that was perceived as a positive for our health care team (reprioritization of care and time saving)

Achieved an outstanding partnership with an innovative team and broadened our opportunities to continually improve patient outcomes

Value

Patient satisfaction scores surrounding pain management initially increased by 68 percent

Automated pain assessments, documentation and notifications created efficiencies for nursing staff, helping them prioritize which patients to follow up with based on their pain rating

St. John’s increased patient satisfaction scores for pain control by 68 percent, as well as decreasing pain scores by frequent, timely reassessment Future plans Goals for next 12 months

• Improve core measures performance (Asthma) • Improve PG/HCAHPS scores in priority focus areas • Achieve best practice for pain management by the Joint Commission • Lower cost per case (decrease length of stay, use of medications, improved percentage of decreased pain reassessment scores) • Provide increased workflow efficiencies for nurses and patient care providers References Habich, Michele, Deeanna Wilson, Dana Thielk, Grace L. Melles, Hillary S. Crumlett, Joyce Masterton, and Julie Mcguire. "Evaluating the Effectiveness of Pediatric Pain Management Guidelines." Journal of Pediatric Nursing 27.4 (2012): 336-45.

Zhou, Huaqiong, Pam Roberts, and Louise Horgan. "Association between Self-report Pain Ratings of Child and Parent, Child and Nurse and Parent and Nurse Dyads: Meta-analysis." Journal of Advanced Nursing 63.4 (2008): 334-42.

Gulur, Padma, Scott W. Rodi, Tabitha A. Washington, Joseph P. Cravero, Gilbert J. Fanciullo, Gregory J. Mchugo, and John C. Baird. "Computer Face Scale for Measuring Pediatric Pain and Mood." The Journal of Pain 10.2 (2009): 173-79.

Cravero, Joseph P., Gilbert J. Fanciullo, Gregory J. Mchugo, and John C. Baird. "The Validity of the Computer Face Scale for Measuring Pediatric Pain and Mood." Ed. Per-Arne Lonnqvist. Pediatric Anesthesia 23.2 (2013): 156-61

Stinson, JN. “Improving the assessment of pediatric chronic pain: Harnessing the potential of electronic diaries.” Pain Research & Management 14:1 (2009)59-64

Questions

• Dr. Jeffrey Suzewits, [email protected] (217) 757-6153

• Rebecca Howard, RN, BSN [email protected] (217)544-6464, 30593

Thank you!

800 East Carpenter Springfield, Illinois 62769

The views expressed today are our opinions and not those of our employer.