Registed Nurses' Association of Ontario

The Transformation of Evidence-Based Knowledge into an Acute Pain Service

Katherine Krupa, MN, RN (EC)-Adult
Cambridge Memorial Hospital

Summary of Fellowship:
In 2014, Cambridge Memorial Hospital began a major capital redevelopment project. The associated growth in capacity and services presented an excellent opportunity to explore the feasibility of an Acute Pain Service (APS) within the organization. This new resource would positively impact the client’s experience during their hospital stay, and continue to impact their recovery and rehabilitation following discharge from hospital. One of Cambridge Memorial Hospital’s strategic goals set for 2014-2017 is to improve the client experience while admitted to our facility. The implementation of a formal Acute Pain Service would positively impact this goal, while also supporting the organization’s core values of caring, compassion, accountability, innovation, and respect.

The goal of this fellowship proposal was to enhance my knowledge and skills as they related to acute pain assessment and management, and to learn the processes involved in the creation and implementation of an APS within a healthcare facility. To achieve this goal, I began by reviewing information on the pathophysiology of pain, and the different classifications of pain. The knowledge gained from this review has been used to create poster-board presentations for display at our organization’s future education fair in the fall of 2017.

I also arranged to observe the activities of the clinicians who manage two established APS’s at hospitals within my geographical region. One APS I observed is managed by Registered Nurses, and the other APS is managed by a Nurse Practitioner, which also provided me with the opportunity to compare the differences/advantages/disadvantages between these two different healthcare clinicians within this role. I found these clinical placements to be the most informative type of learning with regards to the actual establishment and management of an APS within an organization. I was able to see firsthand the daily flow of the service, the inter-professional collaboration between contributors to the APS, and the improved pain management of the patients served by the APS. I was also offered many educational and informative resources from my Team Mentors at both clinical placements, including pre-printed order sets, pain assessment templates, and the titles of reference materials used regularly by the APS clinicians.

The knowledge gained from this fellowship has assisted in promoting policy and protocol change within the organization, and in preparing the organization for a new and valuable resource, an APS. Shortly after beginning my fellowship experience, I applied for and became the successful candidate for the role of Nurse Practitioner for the new APS at Cambridge Memorial Hospital. I was able to complete my clinical placements prior to starting in this new role, which was extremely helpful since it prepared me for the necessary documentation, flow, and assessment requirements paramount to the successful implementation of an APS. The resources I obtained from my Team Mentors have been invaluable as I work within my new role. I have established a monthly meeting with Anesthesia staff to discuss the goals and future direction of the new APS. I also meet weekly with my Chief Nursing Executive regarding the progress of the APS, and regarding my new role as the only in-patient Nurse Practitioner within my organization. I have successfully enlisted a Director for the APS, who is an invaluable resource for me and the service itself, as we begin to initiate change in the analgesia regimes offered to our patients.

Another benefit generated from the clinical placements was the opportunity to see different modalities of analgesia regimes being utilized within each organization, and how successful these regimes are. Some examples include: periarticular blocks for total knee arthroplasty; the utilization of a strictly oral analgesia regime where controlled-release opioids are given on a scheduled basis and the patient can request immediate-release opioids when needed; epidural infusion boluses being administered by the floor RN’s as per an approved algorithm; and patientcontrolled analgesia using solutions of opioids combined with ketamine for patients with chronic pain issues. I have discussed each of these different modalities at the monthly APS meetings, and as a group, the APS has decided to implement a new oral analgesia regime for total knee arthroplasties which will also utilize periarticular blocks.

Many staff members have embraced the new APS and its role in the care of our patients because they have seen the benefits the service generates for the patients, either in another organization, or within our own organization. Many staff members, however, are still hesitant to fully support the service, or my role within it, because they are reluctant to embrace change, or because they are not yet convinced of the value the service will bring to patient care. In order to facilitate this change in practice, and to gain further acceptance for the APS, I have presented two informative education sessions at Nursing Rounds entitled “The New APS at Cambridge Memorial”. The education sessions were well attended, and generated good questions and discussions during the presentations. I have also provided “mini-education breaks” to the floor staff on a few occasions. These sessions usually last less than ten minutes, and answer a question, or explain a concept initiated by the staff. Since the implementation of the new APS at Cambridge Memorial Hospital, I have seen an increasing acceptance of the APS and my role within the service, as evidenced by staff seeking my advice regarding analgesia options for their patients, requests for APS referrals from surgeons and staff members, and interest in the new oral analgesia regime the APS is preparing to trial for total knee arthroplasties.

Overall Experience:
The most important knowledge I have gained through completion of this fellowship would be that inter-professional collaboration is key to the successful implementation of any new service within an organization. For the APS to be successful, the knowledge, expertise and suggestions from all contributors to the APS framework must be acknowledged, and then evaluated for evidencesupported benefits before being implemented within the service.

I look forward to utilizing the knowledge, expertise and skill I have gained as a result of this fellowship as I progress in my new role within our new APS. I feel great enthusiasm in providing education to staff within the organization on analgesia, bringing new analgesia options to the patients I care for, and increasing the patient’s relief from pain to the highest possible level.