Using Evidence-based Practice Algorithm Improves Outcomes for Patients with Mucositis Pain

BOSTON—Up to 70% of patients undergoing bone marrow transplantation suffer oral mucositis painful enough to require treatment with intravenous opioids. Nurses in the bone marrow transplant unit at Dana-Farber Cancer Institute in Boston became concerned that the lack of practice standards for managing this type of pain was resulting in suboptimal treatment and increasing the risk of adverse events. Barbara Fine, RN, BSN, and Maureen Lynch, MS, RN, developed an evidence-based practice algorithm and an approach to implementing it that was successful in changing established practice, improving outcomes, and increasing staff and patient satisfaction with pain control.

The immediate inspiration for this project was a series of 11 critical incidents, each involving the use of continuous infusion opioids that occurred over a 7-month period in the bone marrow transplant unit. Ms. Fine said that at that time, pain management was determined by the individual nurse’s experience and preference. "Continuous infusion fentanyl was often the drug of choice, and patients often also received antiemetics and anxiolytics," Ms. Fine said.

Re-evaluation Task Force

A task force was convened to re-evaluate the unit’s pain management practices in light of these problems related to polypharmacy. This group included bone marrow transplant unit nurses, a nurse manager, a nurse practitioner with special training in pain management, and clinical pharmacists. The task force assessed each critical incident, reviewed the medical literature on mucositis pain, consulted staff at other transplant centers about pain management approaches and outcomes, and conferred with experts in both pain management and stomatitis treatment. In all of these areas the task force focused on pain management, total opioid use, the number of critical incidents, and patient and nurse satisfaction.

The product of this evidence review was a mucositis pain management algorithm based on patient-controlled analgesia (PCA) with morphine (with or without continuous infusion) rather than fentanyl. This represented a major change in practice for many staff on the unit, so the task force devised an implementation plan incorporating the organizational psychology concepts of "change theory," which assumes that for change to occur, moving through stages of denial, resistance, acceptance, and engagement is required.

The mucositis pain management implementation program included information packets from the evidence review, individual and small group feedback sessions to elicit and address the nurses’ concerns, and a 2-month pilot trial of the new algorithm. The researchers collected data on opioid utilization, pain intensity scores, patient satisfaction with pain control, and nurse satisfaction with pain control.

Strong Support for Plan

"We had strong support of the pain service at the hospital and strong clinical support. This was important, since none of the nurses involved had previous experience with PCA," Ms. Fine said.

Eighteen patients who had PCA with or without continuous infusions were evaluated and reported strong satisfaction with the PCA program. Ms. Fine noted that many commented on the immediate pain relief provided by PCA.

"There was also strong positive feedback from the staff, and this is from a unit that had previously been strongly resistant to change," Ms. Fine said. "Our study demonstrated that an evidence-based practice guideline can improve care for patients with mucositis pain. At our institution we were able to implement a new standard of care, and the continued use of this algorithm by nursing staff on the unit illustrates the success of this approach in achieving changes in clinical practice."