MOPATA new tool for assessing pain in hospice patients who can’t self-

report

Presenters:Deborah Bortle, MS, BSN, CHPN

Joan K. Harrold, MD, MPH, FACP, FAAHPM

Pain Assessment in Hospice PatientsPatients able to self-reportPatients not able to self-report

How do we it?What are the challenges?What do we need?

MOPAT: Multidimensional Objective Pain Assessment ToolUniversity of Maryland School of Nursing

Preliminary work (McGuire & Reifsnyder, 2004) suggested that at least 2 dimensions of acute pain—behavioral and physiologic—could be assessed in non-communicative palliative care patients.

Goal: to validate the MOPAT and demonstrate its feasibility in a spectrum of palliative care settings when used by both nurses and informal caregivers to assess acute pain in non-communicative patients.

MOPATHospice of Lancaster County

ADC 450-50012 bed IPU, mainly GIPSecond IPU opened, 16 beds, mainly GIPResearch MS/BSN 0.5 FTEOn-site IS manager to enable EMR data

collection

MOPAT in HospiceRemove blood pressure measurementsNot routinely performed, especially at EOLCould limit future clinical utility

Staff other than nursesOther caregivers

Study DesignEligible IPU patients suspected of having painSimultaneous MOPAT assessments by Study

RN and Staff nurse (RN or LPN)1 primary Study RN with 1 back-up

Reassessment following interventionTiming based on intervention used

Staff MOPAT results documented in EMRStudy MOPAT results not included in patient

recordSerial values were used clinically even if not

recorded for the study

Inclusions/ExclusionsInclusion

Adults with evidence of pain and not able to self-report

ExclusionsNon-responsivePediatric < 18 years oldRAST < 5Any diagnosis of dementia

Behavioral Subscale

Behavioral Pain Indicators 0 (None or Normal) 1 (Mild) 2 (Moderate) 3 (Severe) Score

Restless Quiet Slightly restless (fidgety)

Moderately restless (tossing/turning)

Very restless (agitated, constant movement)

Tense Muscles

(Muscle Tension)

Relaxed Slight tenseness (Guarding) Moderate tenseness (sensitivity or mild resistance to movement)

Extreme tenseness (stiffness or total body rigidity)

Frowning/Grimacing

(Facial Expression)

No frowning or grimacing Slight frowning or grimacing (furrowed brow)

Moderate frowning or grimacing Constant frowning or grimacing

Patient Sounds (Vocalization)

(Record ‘4’ if unable to vocalize)

Quiet Sighs, groans, moans softly Groans, moans loudly Cries out or sobs

Behavioral Score

Physiological Subscale

Physiological Pain Indicators 0 (Usual or No Change from Usual) 1 (Not Usual or Change from Usual) Score

Heart Rate Usual/No Change Change from usual

Respirations Usual/No Change Change from usual

Diaphoresis Usual/Absent Present

Physiological Score

TOTAL SCORE

MOPAT

Recruitment and EducationHospice decided MOPAT to be used in IPU

for all patientsRegardless of patient enrollment in studyEvery IPU nurse trained on MOPATMOPAT Incorporated into IPU EMR

UMd created a video of case scenariosRevised for hospice environmentUnit Director volunteered to be patient in videoResearchers and IPU leaders performed

consensus ratings prior to use for training

TrainingTrained staff over 3 months

39 RNs and 22 LPNs agreed to participate in study1 RN and 1 LPN declined, but still utilized MOPATSame instructor for everyoneOut of the IPU for trainingAssociated color: PURPLE magnetsIncluded snacksThank you gift: MOPAT clipboard

Feedback via fliers when general issues identified

Clinical Utility AssessmentCompleted monthly by nurses who

volunteered to participate in this arm of studyNo additional incentives

Did nurses like the tool?Would they use the tool?

Patient EnrollmentProject began March 7, 2009

Nurses had 3-5 months to use before enrollment patient

50 patients enrolled by December 11, 2009Last patient enrolled November 23, 201021 month enrollment period for 100 patients

Challenges to EnrollmentIPU transfers 5pm-8am and on SaturdaysOpening of new IPU 7 miles awayReasons not enrolled:

50% diagnoses included dementia22% died prior to study assessment20% died before re-assessment2% study nurse not available2% RAST < 5

Results: Nurses using MOPAT

0

20

40

60

80

100

Mar

Sept

Mar

Sept

Results: Return Rate CUQ’s (%)

0

20

40

60

80

100

Results of MOPAT in HospiceReliability

Agreement between Study nurse and Staff Nurse raters was significant at p<.001, with moderate-substantial agreement on most indicators.

ValidityValidity was evidenced by statistically

significant (p<.001) reductions in behavioral, physiologic, and total MOPAT scores following pain interventions.

Clinical Utility Questionnaire Strongly

Disagree Disagree Undecided Agree

Strongly Agree

1. MOPAT took a reasonable amount of time to complete.

1 2 3 4 5

2. MOPAT was easy to use.

1 2 3 4 5

3. MOPAT would be feasible for regular use in my clinical setting.

1 2 3 4 5

4. MOPAT was easy for me to understand.

1 2 3 4 5

5. MOPAT guided me in what to look for when assessing pain.

1 2 3 4 5

6. MOPAT assisted me in communicating to others about a patient’s pain.

1 2 3 4 5

7. MOPAT was helpful in determining the presence of pain in a non-communicative patient.

1 2 3 4 5

8. MOPAT was helpful in determining whether a patient might need a pain intervention.

1 2 3 4 5

9. MOPAT could be used by informal caregivers (family, friends) with some training.

1 2 3 4 5

Results: UtilityGuided pain assessmentAssisted in communicationHelped determine if pain

presentHelped determine

intervention needed

63.9%61.1%61.6%60.3%

Results: Ease of UseReasonable time to complete 63.8%Easy to use 71.5%Feasible for regular use 57.3%Easy to understand 71.8%

Adjustments to MOPATEliminate diaphoresis on MOPAT tool

Added no valueShortened time to complete

Home Hospice Roll-outRoll out to admission team first

Tried to get their feedback before HH roll outEasier to use than they expectedLiked an objective toolDidn’t like having another form to complete

Recognized need for standardized tool for patients with dementia who cannot self-report Dementia in IPU accounted for 50% of those

excluded from MOPAT studyPAINAD added to EMR prior to HH roll-out

Home Hospice TrainingPower point presentation in IDT plus make-up

sessionsAll IDT members includedWritten case scenarios for selection of

appropriate toolMOPAT and PAINAD tools in handouts

Flow chart on how to document your pain assessment

Self report—if unable, choose either… PAINAD MOPAT

Issues in Home HospiceNurses using assessment tools interchangeably

Even for same patient More than expected from fluctuations in clinical status Using self-report while awake and MOPAT while asleep Using MOPAT and PAINAD for same patient

Nurses only using a tool after they determine patient has painNeed to use to help determine if a patient has painAllows next clinician to compare pain levels using

same variablesCommunication, not clinical accuracy

Issues in Home HospiceDefinition of dementia

34.8% with dementia had a MOPAT completedEmphasize self-report first!What constitutes a diagnosis of dementia?

Problem or dx list? Family report? Clinical notes?

Timing of focus on NQF #0209Comfort in 48 hoursSelf-report onlyDiminished focus on assessment of patients

who cannot self-report

Lessons LearnedRoll-out with fanfare

Need excitement to make an impressionDon’t roll-out with too many other new thingsUse the video scenarios in all trainingAsk for feedback

Can use the CUQ, but not every month!Deliver rapid feedback to teams on MOPAT

useDevelop organizational policy regarding

dementia diagnosis

Future DirectionsUse CUQ’s to get nursing feedback in Home

HospiceBeginning January 2013

Explore use by other caregiversNursing home cliniciansCaregivers at homeCUQ: MOPAT could be used by informal

caregivers 1.9% disagree 39.8% undecided 58.2% agree

Appreciation to Our ColleaguesDeborah McGuire, PhD, RN, FAAN

Principal investigatorKaren Kaiser, PhD, RN-BC, AOCN Karen Soeken, PhDJoAnne Reifsnyder, PhD, ACHPN