Multifaceted Interventions to Ameliorate Pain/Symptoms

描述（由申请人提供）：疼痛仍然是养老院中体弱老年人发病的重要原因。多达83%的养老院居民抱怨疼痛。通常，养老院居民对疼痛的抱怨不被认可或没有得到适当的治疗。大量的科学证据基础证明了现成的药物和非药物治疗疼痛的方法。利用持续质量改进的研究，包括最近由老年学和卫生保健研究中心与RI质量伙伴合作完成的一项研究，已经影响了护士在评估、记录和使用非药物治疗疼痛方面的行为。这项研究使疼痛减轻了33%。然而，我们的干预对医生禁止行为没有显著影响。根据护士协调员的汇报和其他研究，护医沟通和医生缺乏知识是适当的疼痛管理的两个重要障碍。在这个R21应用中，我们建议开发和试点测试一个基于个人数字助理（PDA）的决策支持干预，用于长期护理中的疼痛管理。这种决策支持将帮助护士进行疼痛评估，提供治疗建议，并打印一份汇总报告，固定在医生办公室。现有的美国老年病学会、美国医学主任协会和AHRQ疼痛管理指南以及专家小组的建议将被用于制定决策支持工具。在开发这一干预措施的过程中，我们将与最终用户（长期护理护士和医生）进行焦点小组讨论，利用认知测试，并进行为期六个月的试点测试，以检查在RI的两家养老院（一个学术基地NH和一个社区基地NH）使用决策支持应用程序。评估将收集有关决策建议的时间、PDA应用程序的可接受性、建议是否被利用以及使用决策支持之前和之后报告的疼痛程度的信息。如果我们成功开发了这种干预措施，R01研究申请将准备进行一项区域随机试验，以确定这种干预措施与快速周期持续质量改善干预措施相结合是否提高了疼痛管理的质量。

DESCRIPTION (provided by applicant): Pain remains an important cause of morbidity for frail, older persons in nursing homes. As high as 83% of nursing home residents voice complaints of pain. Often, nursing home residents' complaints of pain are not recognized or not appropriately treated. A substantial scientific evidence base attests to readily available pharmacological and non-pharmacological modalities to treat pain. Research utilizing continuous quality improvement, including a recently completed study by Center for Gerontology and Health Care Research in cooperation with RI Quality Partners, has impacted on nurses' behavior in the assessment, documentation, and the use of non-pharmacological treatment of pain. This study resulted in 33% reduction in pain. However, our intervention did not significantly impact on physician proscribing behavior. Based on debriefing of nurse coordinators and others research, nurse-physician communication and physicians' lack of knowledge are two important barriers to appropriate pain management. In this R21 application, we propose to develop and pilot test a Personal Digital Assistant (PDA) based decision support intervention for pain management in long term care. This decision support will assist the nurses in conducting a pain assessment, provide treatment recommendation(s), and print a summary report to be fixed to the physician office. Existing guide lines from the American Geriatric Society, American Medical Director Association, and AHRQ pain management guidelines as well as the advice of expert panel will be utilized to formulate decision support tool. In the development of this intervention, we will conduct focus groups with end users (long term care nurses and physicians), utilize cognitive testing, and conduct a six month pilot test that will examine the use of the decision support application in two nursing homes in RI (one academic base NH and one community base NH). An evaluation will collect information on the time to decision recommendation, acceptability of the PDA application, whether recommendations were utilized, and the reported level of pain prior to and after the use of decision support. If we are successful in development of this intervention, a R01 research application will be prepared to conduct a block randomized trial of whether this intervention when combined with the rapid cycle continuous quality improvement intervention improves quality of pain management.