Institutional initiatives are interventions done by an organization to facilitate uptake and implementation of new knowledge by healthcare providers, patients, and caregivers to improve care. Interventions include provision of education and distribution of printed materials, and may include development of organizational protocols, procedures, and activities to standardize care. Institutional interventions were evaluated in terms of effect on chronic pain and prevention of infection in patients with cancer.
Effectiveness Not Established
Cummings, G.G., Olivo, S.A., Biondo, P.D., Stiles, C.R., Yurtseven, O., Fainsinger, R.L., & Hagen, N.A. (2011). Effectiveness of knowledge translation interventions to improve cancer pain management. Journal of Pain and Symptom Management, 41, 915–939.doi: 10.1016/j.jpainsymman.2010.07.017
To determine the effectiveness of interventions to facilitate uptake of new knowledge by healthcare practitioners, patients, and family caregivers to improve cancer pain management. Primary outcomes of interest were change in behavior or practice of healthcare professionals or patients and caregivers. Secondary outcomes included change in patient quality of life or satisfaction with treatment.
Databases searched were CINAHL, MEDLINE, EMBASE, AMED, Web of Science, Cochrane Database of Clinical Trials and Cochrane Database of Systematic Reviews, National Cancer Institute of Canada, Canadian Cancer Society, American Cancer Society, American Society of Clinical Oncology, European Association for Palliative Care, and other websites.
An extensive listing of specific search terms and operators is provided. Main search terms included pain, analgesia, cancer, practice guidelines, evidence based medicine, and organizational innovation.
Studies were included in the review if they
- Were randomized controlled trials, controlled clinical trials, time series, and pre-post studies that evaluated the effect of knowledge translation interventions on patient outcomes
- Included patients with cancer.
Case reports, cross-sectional studies, or noncontrolled pre-post studies were excluded.
- The initial search yielded 15,625 articles.
- A total of 308 articles were retrieved and reviewed according to inclusion criteria.
- Risk of bias assessment was done using methods of the Cochrane Effective Practice and Organization of Care Group.
A final sample of 26 studies was included: 16 examined interventions for patients only, 4 focused on family caregivers, and 5 investigated effects of interventions targeted to health professionals. One study compared a solo intervention for patients only, and a dyad intervention for patients and their significant others, within the same study.
- Of 26 studies, 25 were rated as having high risk of bias due to lack of blinding in the design, incomplete data, lack of allocation concealment, and other issues. Inter-rater reliability of this scoring showed only slight agreement between raters.
Interventions targeting health professionals (5 studies)
- Findings related to patient outcomes were mixed, with two studies showing decrease in pain intensity and two studies showing no change in patients’ pain.
- Two studies showed significant increases in healthcare professionals’ knowledge and attitudes.
Interventions targeting patients and caregivers (21 studies)
- Most interventions were face-to-face coaching sessions and distribution of printed material. In more than half of the studies, in-person or telephone follow-up was used to reinforce education.
- Eight studies showed significant decrease in patients’ pain intensity with the intervention, and five showed positive change in patient behavior regarding pain control strategies.
- Five studies targeting patients and family caregivers showed mixed results, with two showing improvement in pain intensity and adherence to therapy, and three showing no effect.
Interventions targeting patients and caregivers
- There was no significant effect of interventions on pain interference with activities.
- In six studies, the effect on usual/average pain showed a tendency favoring the intervention (SMD = 0.43, 95% CI 0.13 – 0.74, effect = 2.76, p = 0.006). These findings are limited by the high heterogeneity among studies.
- There was no significant overall effect of interventions on worst pain, current pain, or overall pain measures in meta-analysis.
- There was a significant effect of the intervention on least pain intensity (SMD = 0.93, 95% CI 0.44 – 0.142, p = 0.0002), but this was from only two studies.
Intervention dose and intensity
- It is noted that the “dose” and intensity of knowledge translation interventions varied greatly. Authors define high- and low-dose parameters and show that those studies with higher dosage of the intervention tended to report significant results on patient outcomes.
Knowledge translation interventions aimed at healthcare professionals have demonstrated change in practitioner behavior and attitude, but have not demonstrated an effect on patient pain outcomes measured. There is some evidence to suggest that higher intensity and “dose” of these interventions, indicating amount of time spent in education, inclusion of follow-up, patient/family contact, and longer duration of follow- up, tend to be more effective.
Knowledge translation interventions aimed at patients and caregivers have been associated with improvement in patients’ least and average pain scores, but not other pain measures. These findings need to be viewed with caution, since studies included showed high heterogeneity, and the timing, dosage, and intensity of the interventions varied.
Educational and knowledge translation interventions regarding pain management that are aimed at the patient and caregiver have been shown to be effective in improving some measures of pain intensity, and have often, but not always, resulted in improved knowledge, attitudes, and skills related to pain management. Elements of success included more intensive education such as involvement of a multidisciplinary team in face-to-face education, locally constructed education materials, standardized approaches, and patient follow-up to reinforce the education. Pain management educational programs should be constructed to include key elements that are likely to improve outcomes.
Goldberg, G.R., & Morrison, R.S. (2007). Pain management in hospitalized cancer patients: A systematic review. Journal of Clinical Oncology, 25, 1792–1801.doi: 10.1200/JCO.2006.07.9038
To provide a systematic review of institutional interventions designed to improve management of pain in hospitalized patients with cancer
Databases searched were MEDLINE, Cochrane Library, and authors’ personal libraries.
Search keywords were pain, pain measurement, outcomes assessment, or quality assurance.
Inclusion criteria was not specifically stated, other than that studies involved patients with cancer.
Exclusion criteria was not specifically stated.
Total number of studies retrieved or initially evaluated is not provided.
Articles were reviewed and independently summarized by the authors, and any disagreements were discussed until consensus was achieved.
Studies were not exclusively for patients with cancer, but all did involve some cancer care cases.
- Four studies involving the effect of educational interventions for care providers, encompassing 939 nurses
- Two studies involving patient education, encompassing 343 patients
- Ten studies of interventions to improve assessment and documentation of pain, involving more than 2,876 cases
- Three studies involving the use of auditing and feedback, involving more than 4,662 patients
- Two studies and one meta-analysis involving use of pain specialty consultation
- One study involving the use of a computerized decision support system (CDSS) to enhance physician prescribing and treatment of pain
Nursing educational interventions improve knowledge and correct misconceptions but have not shown improved pain or patient satisfaction.
Studies suggest that patient education and tailored counseling sessions directed at patients can improve pain scores and negative beliefs and misconceptions.
Routine pain assessment has been shown to improve staff and patient satisfaction; however, interventions have not been shown to improve overall pain scores or pain severity.
Provision of audit and feedback of patient pain scores to nursing staff improved pain assessment rates but had no effect on pain severity.
The study involving CDSS showed some improvement in prescribing practices, predominantly reducing use of meperidine, but did not demonstrate improved pain scores.
Meta-analysis of eight studies in the effect of a hospital-based palliative care team suggests that referral to such programs results in small but positive effects on pain, other symptoms, satisfaction, and reduction in length of stay compared to conventional care.
The major types of institution-wide interventions aimed at improving pain management include education, inclusion of pain assessment as a vital sign, auditing and staff feedback of pain scores, use of CDSS, and referral to palliative care specialists. Improved knowledge, assessment, and process of care measures have been demonstrated; however, no substantial effects on actual pain scores and severity have been demonstrated as a result of these interventions. From this review, the most promising interventions related to actual pain outcomes appear to be patient education and counseling and referral to palliative care specialists. The authors conclude that no generalizable interventions were identified.
- Findings are limited by the fact that studies had numerous methodological flaws and, in some cases, very small samples.
- The search strategy was limited and not well-reported and may have missed reports of some quality improvement efforts that may have not been published or identified in this review.
Findings point to the difficulty of being able to demonstrate the effects of institutional interventions on patients’ measurable pain outcomes other than satisfaction with pain management. Most of these efforts are not necessarily appropriate in a randomized controlled trial type of design, leading to questions of methodological rigor in findings, and suggest that the patient’s experience of pain is complex and not readily determined by standardized processes.
Findings suggest that individual patient interventions including counseling and education are worth further investigation in order to have an effect on pain outcomes.
Involvement of palliative care specialists appears to be somewhat effective to improve pain outcomes; however, it is not clear that universal referrals to such groups for all pain management are practical. This raises the question of how such specialized knowledge, focus, and expertise might be shared and utilized in new ways to impact all patients. It is not clear that educational interventions for staff that have been studied are sufficient to improve knowledge of providers to the extent required to impact pain-related results.
Research Evidence Summaries
Herr, K., Titler, M., Fine, P.G., Sanders, S., Cavanaugh, J.E., Swegle, J., . . . Forcucci, C. (2012). The effect of a translating research into practice (TRIP)-cancer intervention on cancer pain management in older adults in hospice. Pain Medicine, 13, 1004–1017.doi: 10.1111/j.1526-4637.2012.01405.x
To promote the adoption of evidence-based pain practices for older adults with cancer
Intervention Characteristics/Basic Study Process:
- Five-month engagement phase—receipt of three relevant clinical practice guidelines for experimental (E) and control (C) groups, pain training and activities for E hospices
- 12-month implementation phase—E group received tools for implementation (e.g., quick reference guides), nurses completed an evidence-based practice (EBP) pain program, sites received a monthly outreach visit from an expert nurse who audited charts for 48 EBP indicators and provided feedback, participation in a monthly teleconference to discuss progress and strategies, sharing on e-sites, weekly pain assessment and management sessions as desired
- N = 16 hospices and 738 patients
- AGE: Hospices see 30 older patients per year; patients were older adults with a mean age of 77.6 years
- MALES: 55.9%, FEMALES: 44.1%
- KEY DISEASE CHARACTERISTICS: End-stage cancer
- OTHER KEY SAMPLE CHARACTERISTICS: 66.3% white
- SITE: Multi-site
- SETTING TYPE: Home
- LOCATION: Midwest hospices
Phase of Care and Clinical Applications:
- PHASE OF CARE: End-of-life care
- APPLICATIONS: Elder care
Retrospective, cluster, randomized control trial of 16 hospices
- Eight in the E group and eight in the C group
- Cancer Pain Practice Index (CPPI), which lists 11 EBP cancer pain practices for older adults
- Mean pain severity
- Medical record abstract tool inclusive of 48 indicators of EBP for pain management
- Numeric Rating Scale
- Pain severity scale (0–10)
- Verbal Descriptor Scale for pain intensity (mild, moderate, severe)
No significant differences existed between the E and C groups in regards to improvement in the CPPI. A decrease in pain severity was found from baseline to post-intervention in the E group, but this was not statistically significant.
Numerous factors influence a multicomponent intervention. Culture, competing priorities, intervention complexity, and other factors may have a role. Future studies should focus on more specific factors in need of change. Although the patient sample was large, only eight hospices comprised each group for the study.
- Small sample (less than 30)
- Intervention expensive, impractical, or training needs
- Other limitations/explanation: The sensitivity of the CPPI to detect change in provider practice was not established a priori.
Translating research into practice is a primary goal of nursing, and pain guideline translation is essential to improving pain outcomes. Translation, however, takes time and may not translate immediately to improved patient outcomes.
Won, Y., Hwa, Choi, Y., Jung, Ahn, S., Lee, J., Park, J., Yun, Kim, S., . . . Kim, Y.H. (2014). Improving the quality of cancer pain management in an academic medical center emergency department. Clinical Journal of Oncology Nursing, 18, 626–629.doi: 10.1188/14.CJON.626-629
To evaluate the impact of a cancer-related pain control project implemented in a specialized cancer emergency department
Intervention Characteristics/Basic Study Process:
A project to improve the management of cancer-related pain was implemented in a cancer emergency department that was established two years prior. The project used standard operating procedures for patient assessments every eight hours and reported any pain within one hour of analgesic administration. The pain management guidelines used included the use of oral analgesics following the World Health Organization analgesic ladder, the use of time-release analgesics for the prevention of pain recurrence, the prophylactic prescription of immediate-release analgesica for breakthrough pain, and the increase of the regular analgesic dose when breakthrough pain occurred more than three times per day. The target pain score on a numeric rating scale was established at three points or less. Medical records were reviewed to obtain study data, and adherence to the guideline and procedures was ranked low, medium, or high based on percent adherence. Findings prior to and after the project's implementation were compared.
- N = 455
- MEAN AGE = 54.9 years
- MALES: 50%, FEMALES: 50%
- KEY DISEASE CHARACTERISTICS: The majority of patients had solid tumors of various types.
- OTHER KEY SAMPLE CHARACTERISTICS: The patients included were those in the emergency department for at least 24 hours.
- SITE: Single site
- SETTING TYPE: Outpatient
- LOCATION: Korea
Phase of Care and Clinical Applications:
- APPLICATIONS: Palliative care
Retrospective, descriptive study
- Pain severity Numeric Rating Scale (NRS)
- Time to reaching target pain NRS score of three or less
- Guideline adherence high (> 75 %), medium (50%–75%), and low (< 50%)
The percentage of patients who received pain assessments according to the procedure increased after the intervention (p < 0.001). There was a significant improvement in the appropriate use of short-acting analgesics (p < 0.001), prescriptions for breakthrough pain analgesics (p = 0.013), and the use of time-release analgesics (p < 0.001). The time to reach the target NRS was 27 hours before the intervention and 15 hours after (p = 0.025). There was a significant correlation between guideline adherence and time to reach the target NRS score (p = 0.039).
The use of standard guidelines and standard operating procedures for the treatment of cancer-related pain was associated with improved frequency of assessment and time to reach a target pain score.
- Risk of bias (no control group)
- Risk of bias (no blinding)
- Risk of bias (no random assignment)
- Key sample group differences that could influence results
- Findings not generalizable
- Other limitations/explanation: The intervention was done in a cancer-specific emergency department. Such a specialized emergency department is not usual. There was no description of how the project and its related changes in practice were actually implemented or what staff education efforts were done to implement the guidelines and procedures.
The findings of this study suggest that organizational initiatives to improve pain control with guidelines and standard operating procedures can improve the management of cancer-related pain.