Managing Acute Pain in Critically Ill Non-communicative Palliative Care Patients

描述（由申请人提供）：本项目响应PA-10-006疼痛研究的机制，模型，测量和管理（R01）。急性住院姑息治疗患者如果不能自我报告疼痛的存在或疼痛的强度，就很有可能对疼痛的认识不足和治疗不足，经历不必要的痛苦和其他不良反应。在提供姑息治疗的环境中，缺乏可靠和有效的措施来评估这些非交流患者的疼痛，并且很少有标准化的协议或算法对患者结果的影响进行测试。我们最近完成的项目（5 R01NR009684）测试了多维客观疼痛评估工具（MOPAT）在评估非沟通姑息治疗患者急性疼痛方面的心理测量特性和临床效用，证明了强有力的有效性、可靠性和临床效用，当训练有素的护士在危重非沟通患者中定期使用时。本研究的主要目的是测试在内科、外科和创伤重症监护病房住院的重症非沟通性姑息治疗患者中，与没有该算法的患者相比，包含MOPAT和镇痛顺序集的疼痛算法是否能改善疼痛严重程度和药物疼痛管理策略的使用。我们假设：（H1）疼痛严重程度降低，（H2）用于疼痛的药物药物数量增加，（H3）由于实施疼痛算法，用于疼痛的药物药物的总等效镇痛剂量增加。次要描述目的是（S1）比较伴有和不伴有疼痛相关疾病的患者的疼痛相关结果，（S2）描述患者疼痛随时间的变化模式，（S3）评估护士对临床的看法

DESCRIPTION (provided by applicant): This project responds to PA-10-006 Mechanisms, Models, Measurement, & Management in Pain Research (R01). Acutely ill hospitalized palliative care patients who cannot self-report the presence or intensity of their pain are at high risk for under-recognition and under-treatment of pain, experiencing needless suffering and other adverse effects. Across the settings in which palliative care is rendered, there is a dearth of reliable and valid measures for assessing pain in these non-communicative patients, and few standardized protocols or algorithms have been tested for their effects on patients' outcomes. Our recently completed project (5 R01NR009684) tested the psychometric properties and clinical utility of the Multidimensional Objective Pain Assessment Tool (MOPAT) in assessing acute pain in non-communicative palliative care patients, demonstrating strong evidence of validity, reliability, and clinical utility when used regularly over time by trained nurses in critcally ill non-communicative patients. The primary aim of the proposed research is to test whether a pain algorithm that incorporates the MOPAT and an analgesic order set improves pain severity and use of pharmacologic pain management strategies in critically ill non-communicative palliative care patients who are hospitalized on medical, surgical, and trauma intensive care units when compared to patients without the algorithm. We hypothesize: (H1) a decrease in pain severity, (H2) an increase in the number of pharmacologic agents used for pain, and (H3) an increase in the total equi-analgesic dosage of pharmacologic agents used for pain as a result of implementation of the pain algorithm. The secondary descriptive aims are to (S1) Compare pain-related outcomes in patients with and without concurrent pain-related conditions, (S2) Describe the pattern of patients' pain over time, and (S3) Evaluate nurses' perceptions of clinical utility of the pain algorithm. We will use a cohort control group quasi-experimental design conducted in two phases on the medical, surgical, and trauma intensive care units of a major university acute care hospital. In Phase 1 (usual care control cohort n=150 patients), the MOPAT will be incorporated into routine clinical practice and data on pain severity and use of pharmacologic pain management strategies collected. In Phase 2 (intervention cohort n=150 patients), a pain algorithm incorporating MOPAT scores into an analgesic order set will be implemented in routine clinical practice and the same patient outcome data plus nurses' perceptions of clinical utility of the algorithm (including the MOPAT) will be collected. Analysis f the primary aim and its associated hypotheses will be accomplished using the interaction F-test from 2x4 repeated measures analysis or mixed linear modeling and Cochran's Q for 2x2 repeated measures on rank data. Descriptive approaches will be used for the secondary aims, including repeated measures analysis with post-hoc analyses if there are significant interaction effects, graphic techniques (e.g., spaghetti plots) to identify sub-groups, and frequency distributions for responses to questionnaires. This research is significant and innovative because it tests a pain algorithm using an instrument validated in non-communicative patients to guide pain management and improve pain- related outcomes in this vulnerable and understudied population.