Bedside Insight: Amazing Nurse Discoveries

Bedside Insight: Amazing Nurse Discoveries

Prior to the 1950s, neonatal jaundice was a common problem and one of the leading causes of death in premature infants — that is, until a British nurse made a fortuitous discovery.

Sister Jean Ward, whose reputation for excellence in rearing puppies landed her a job running the preemie unit at Rochford General Hospital in Essex, England, was a “keen” believer in the restorative effects of fresh air and sunshine and on warm days would wheel the frailer infants into the hospital’s sunny courtyard.

Not wanting to raise any eyebrows with her unorthodox practice, Ward would usually scurry the babies back inside to their incubators before the hospital’s pediatricians made their rounds.

But one afternoon in 1956, Ward ushered a group of doctors over and sheepishly showed them the preemie in her care. The infant was pale yellow from head to toe, except for one deeply bronzed triangle of skin.

Mystified, one of the doctors asked if she had painted that portion of the baby’s skin with iodine. It wasn’t a paint job, Ward assured him. The darker patch of jaundiced skin had been covered up by the corner of a sheet while the infant was outside. It was the rest of the infant’s yellowish skin that had faded, she explained, apparently from the sun exposure.

Ward’s astute observations helped to pave the way for phototherapy treatments that are still used today to treat infants suffering from hyperbilirubinemia — and she’s just one of many nurses whose bedside discoveries have revolutionized the way we care for patients.

Other groundbreaking nurse inventions, as noted in this 2014 Medscape article, include everything from disposable sanitary napkins to crash carts to ostomy bags to disposable baby bottles. It was also a nurse, who in 1911, created the first mannequin to function as a patient simulator for nurses in training — and newer generations of nurse inventors and researchers are tackling other vexing problems in health care.

With hospital-acquired infections on the rise, Ginny Porowski worried about the health hazard created by waste bins overflowing with contaminated isolation gowns — a common sight on any floor with patients on contact precautions. So a few years ago, the North Carolina nurse invented a new type of gown that can be disposed of more easily. Unlike the typical isolation gear, Porowski’s GoGown has a special inside panel allowing the wearer to wrap a used gown into a small, compact bundle for safer disposal. Health care providers never have to touch the outside of the gown and used bundles sink to the bottom of the trash container, rather than billowing out the top.

A Chicago-area nurse’s research, meanwhile, is changing the way some Illinois hospitals approach newborns’ first baths.

Courtney Buss, an RN at Advocate Sherman Hospital in Elgin, Illinois had been hearing a lot of buzz about the benefits of delaying a newborn’s first bath for at least eight to 24 hours, but she was unable to find much in the way hard evidence supporting the “wait-to-bathe” approach. Looking for answers, she decided to conduct her own investigation.

At most hospitals, newborns typically receive a sponge bath soon after birth to remove the white, waxy, cheese-like substance called vernix caseosa that covers their body.  But Buss’s 2016 study showed that leaving the protective layer of vernix intact for at least 14 hours can dramatically reduce bouts of hypothermia and hypoglycemia in newborns.

Over the course of nine months, as bathing was delayed, Buss found that the percentage of infants suffering from hypothermia dropped from nearly 30% to 7% and hypoglycemia rates plummeted from 21% to 4%, according to the Chicago Tribune. Delayed bathing also dramatically improved breastfeeding rates among the babies because the vernix helps neonates pick up on their mother’s scent, which makes latching easier.

The hospital system where Buss works has since instituted a “wait to bathe” policy at half its hospitals and her research underscores what the nursing profession has long known — that important discoveries aren’t restricted to those in white lab coats. Innovative scientists also wear scrubs and even answer call bells.

When Words Do Harm

When Words Do Harm

Last year, the American Diabetes Association prohibited the use of the word “diabetic” to describe patients in its publications. And at a recent conference, the group cautioned health care providers against using the “ic” term and other words that might alienate patients.

Among the objectionable words: “uncontrolled,” “non-adherent,” and “non-compliant.” Even using words like “good” and “bad” to characterize a patient’s blood glucose levels can have a negative impact, diabetes experts say, leaving patients feeling judged and stigmatized.

Better choices, they say, would be “in range” or “out of range,” or “high” or “low” — and it’s not just a matter of semantics. How we talk about diabetes directly impacts patients’ behavior.

If this sounds a bit far-fetched, think about it this way: When you tell the night shift nurse during bedside shift report that “Mr. Smith is a 54-year-old diabetic” you’ve just defined Mr. Smith’s entire being by his disease. When you jot down that Mrs. Jones has been “non-compliant” because she hasn’t been regularly testing her blood glucose levels, she feels the sting of a scolding—and maybe a sense of personal failure, too.

At the end of the day, these judgmental words and phrases can erode an individual’s motivation and actually worsen their blood glucose control. That’s because it contributes to “diabetes distress”—the fear and futility that creeps into a patient’s head when the process of managing diabetes begins to seem overwhelming.

It’s not just in the endocrinology clinic that words can do harm. A 2010 study published in the journal Spine found that patients with low back pain had a more negative perception of their prognosis when their physicians attributed their back pain to a “degenerative” process involving “wear and tear” of the spine or “crumbling” or “collapsing” discs.  In essence, when it sounded bad, the patients viewed their condition as worse than it necessarily was—and that hopeless mindset made them more hesitant to engage in therapies that might actually improve their health.

The impact of word choice is especially evident in psychiatric care and nurses should be careful to avoid using stigmatizing language. In an article published last year in the Journal of the American Medical Association, then-drug czar Michael Botticelli and Harvard professor Howard Koh opined that it wasn’t all that long ago that individuals with mental illness were referred to as “lunatics” and the hospitals where they were treated as “insane asylums.”

Just as those insensitive terms were appropriately abandoned, we need to rethink the way we talk about problems like addiction. A patient isn’t a “drug abuser;” they’re a “person with a substance abuse disorder.” Instead of referring to drug results as “clean” or “dirty,” they should be characterized as “positive” or “negative,” or “substance-free.” The word “drug habit” is problematic too, because it can imply that a substance abuse disorder is a personal choice, rather than simply a disease.

As we incorporate a better vocabulary into our practices, we must also remember that non-verbal language can be just as powerful as the spoken word.

For me, that lesson became crystal clear several years ago while caring for a patient who’d been hospitalized for a warfarin-associated G.I. bleed.

It had been a rough 24 hours, but after several bags of vitamin K, the patient appeared to be improving significantly. His INR was coming down and the attending had just told him that he was out of the proverbial woods. So I was flummoxed when the patient burst into tears as I was taking his vital signs.

“Are you in pain? What’s wrong?” I frantically asked.

The usually cheerful, middle-aged man grabbed my hand, sniffled, and in between unrestrained, breathless sobs asked me if he was dying. “I’ve been watching you all morning,” he confided, “and every time you take my blood pressure, you have this terrible, serious look on your face—so I figured I must be dying and you’re just too nice to tell me.”

That day I learned that language is more than just words, and I began to practice my poker face.

Battling Alarm Fatigue

Battling Alarm Fatigue

During the course of a typical 12-hour shift, and depending on the unit, the bedside nurse may encounter hundreds, if not thousands, of alarms generated by patient monitoring equipment. From chirping ventilators to beeping infusion pumps to chiming heart rate monitors, the barrage of noise is so ubiquitous that some nurses even dream about alarms in their sleep.

The alarms are designed to catch a patient in crisis—to signal a dangerous heart rhythm, or plummeting oxygen levels, for instance—and many times, they are lifesaving. But more often, the alerts are false, and the excessive cacophony of pings, rings, and chimes has given rise to a phenomenon known as “alarm fatigue,” whereby overwhelmed nurses and other caregivers become desensitized to the racket and tune it out like background noise.

“I worked in ICUs for 30 years and you truly almost don’t hear it,” says Marc Schlessinger, RRT, MBA, FACHE, a senior associate at the ECRI Institute, a non-profit that evaluates medical devices and works on patient safety issues. “You become so immune to it, that when it’s truly a critical alarm that you have to react to, you may miss it.”

That appears to be what happened two years ago at Vibra Hospital in San Diego when staff failed to respond to a patient’s ventilator alarm for 12 minutes.

According to a report released by California state health regulators, sometime in the early morning hours of May 4, 2014, a portion of the patient’s ventilator tubing became disconnected and a loud alarm began sounding. As the patient’s oxygen levels plummeted, dozens of pages were dispatched to a licensed vocational nurse on duty and a respiratory technician—but no one immediately responded.

The patient’s nurse, who was just 13 feet away at the nurses’ station, said she heard the ventilator alarm going off, but it didn’t occur to her there was a problem. “It was just a vent alarm, it’s not like the oxygen saturation alarm, so I didn’t think anything of it,” she told state regulators. By the time staff responded, the patient was blue and unresponsive. She died 28 days later.

Such incidents are all too common. According to the Joint Commission, alarm fatigue was the single most common factor contributing to 98 alarm-related sentinel events between 2009 and 2012, 80 of which resulted in death. A 2011 investigation by The Boston Globe, meanwhile, identified at least 216 deaths nationwide between 2005 and 2010 that associated with problems with monitoring alarms. Alarm fatigue, the Globe found, was often the root cause.

Tackling the Problem

While there are no easy fixes, hospitals and researchers are taking steps to tackle the vexing problem.

Boston Medical Center (BMC) has dramatically reduced the number of nuisance alarms in its institution by better managing equipment default settings. After mining alarm data on a cardiac telemetry unit, BMC found that the vast majority of false alarms were generated by clinically insignificant changes in heart rate or rhythm that would set off two-beep “warnings” that would typically reset on their own. All told, these self-resetting alarms were generating 175,646 beeps per week.

To cut down on the noise, BMC eliminated the low-priority alarms and elevated more serious alarms to “crisis level,” which triggers three beeps and requires the nurses to review and respond each time it sounds. Other key changes included tweaking low and high heart rate parameters and empowering nurses to personally tailor alarm settings for patients. So far, the strategy seems to be working. Since implementing the changes hospital wide, BMC has reported a 60% drop in alarm noise, nurses seem less stressed, and patient satisfaction scores have improved.

Other institutions, meanwhile, have turned to central monitoring as a solution. At Nemours Children’s Hospital in Central Florida, pediatric med-surg patients are remotely monitored by a team of paramedics who track the patients’ vitals and alarms 24/7. They can visualize the patient in bed, if need be, via a high-resolution camera installed in each room.

If the paramedic detects that a child is in distress or sees a concerning trend, they can promptly alert the patient’s nurse, call a rapid response, or initiate a code blue. Or if an alarm sounds and they see that the patient is just jumping on the bed, they can let the nurse know that too, explains Daniela Melendez, nurse manager of Nemours’ Clinical Logistics Center.  “There’s that peace of mind for that nurse that they didn’t have to stop what they were doing taking care of their current patient to go tend to something that really didn’t need their attention at that moment.”

Richard Fidler, a critical care nurse practitioner, nurse anesthetist, and assistant adjunct professor at University of California San Francisco School of Nursing, worries that too often the reflexive reaction to alarm fatigue is simply to silence the alarms. “They are just bothersome and most of the time, the only thing people know about interacting with the monitor and alarms is where is the silence button… The reaction isn’t why is it alarming, but how do I stop it?”

To help clinicians better sort through the data and the din, Fidler and his UCSF colleagues are working on designing a “super alarm” that could filter out irrelevant information, while at the same time recognizing and alerting caregivers to significant trends. Fidler provides the hypothetical example of patient who comes into the hospital with a heart rate of 65 bpm and develops a gastrointestinal hemorrhage. Over six hours, the patient’s heart rate climbs to 125. In today’s world, those heart rates probably wouldn’t trigger a single alarm, “though the patient is obviously headed south pretty quickly.”

Already, the UCSF team, which is led by biomedical engineer and associate professor Xiao Hu, has shown that they can accurately predict impending code blue events in ICU patients hours in advance by honing in on certain ECG changes that current monitoring can’t detect.

Tips to Reduce Alarm Fatigue

Until better technological solutions are widely available, experts offer these pieces of advice to hospitals and RNs seeking to reduce the problem of alarm exhaustion.

1. Reduce Nuisance Alarms.

ECRI’s Schlessinger says the number one thing hospitals can do is decrease non-actionable alarms. “A perfect example of a non-actionable alarm would be a ventilator where you have one or maybe two high pressure alerts and you’re not going to get off your chair and do anything, because truly nothing needs to be done,” explains Schlessinger. “A similar alarm would be a transient heart rate alarm, or a low pulse ox. A non-actionable alarm is something that truly corrects itself in a matter of seconds with no intervention required.”

2. Tailor Settings.

Many clinicians simply rely on the default alarm settings created by the manufacturer, but one size does not fit all. A patient with severe COPD, for instance, would have a dramatically different baseline EtCO2 and SpO2 levels than a patient without lung disease. Schlessinger says the ECRI recommends hospitals have a “policy that alarms be tailored to each patient—and it doesn’t matter if it’s a ventilator alarm, if it’s a heart rate alarm, pulse ox, whatever. It should be tailored to each patient’s individual needs.”

3. Ensure Good Electrode Contact.  

Loose electrodes are a frequent cause of false alarms. Proper skin prep can greatly reduce artifact on electrocardiogram monitoring. Some institutions require the daily replacement of EKG electrodes to avoid problems.

4. Educate the Patient.

Nurses aren’t the only ones affected by alarm noise. Patients also get exhausted by the cacophony and slow staff response to alarms can add to their worry, says Fidler. “It may actually make them start wondering, ‘Is this not a good hospital? Are the staff not good? Why are they not coming in here when this thing beeps?” Whenever possible, explain to patients and their families why alarms are sounding and what they mean.

5. Avoid Over-Monitoring.

Consider whether your patient requires monitoring, what the appropriate level of monitoring might be and have a collaborative conversation about it. “This practice of putting a patient on a telemetry unit, or monitored unit, because they get a lower nurse-to-patient ratio has got to stop, because you’re contributing to alarm fatigue by putting people who don’t need monitoring on the monitor,” advises UCSF’s Fidler. “Conversely, I don’t want somebody saying ‘Oh, he [sets off] too many alarms, take him off the monitor.’”

6. Join Your Alarm Management Committee.

As of January, the Joint Commission requires every hospital to have an alarm management strategy in place and input from those on the frontlines of patient care is invaluable. If your hospital doesn’t have an alarm management committee, consider starting one. “Every new thing coming into the hospital has some kind of alarm attached to it. Even if it’s a power disconnect alarm—everything has some kind of alarm,” says Fidler.

Three Superbugs Nurses Need to Know

Three Superbugs Nurses Need to Know

Bill Warner, a concrete mixer driver in North Carolina, had always been a “strong” and “innovative” man, according to his wife, Carla. But after undergoing a routine endoscopic procedure at a local hospital in early 2013, the once robust 55-year-old developed a raging infection—a superbug—that rendered him “unable to do even the simplest tasks for himself,” his widow recounted last year in testimony before the U.S. Food and Drug Administration.

Warner, it turns out, had contracted Carbapenem-resistant Enterobacteriaceae, or CRE, a highly resistant bacteria that kills up to half of patients infected with it. The superbug ravaged Warner’s body. He lost more than 60 pounds, required tube feedings and was racked with excruciating pain. In November of 2013, after eight months of battling the infection, he died.

Drug-resistant organisms like the one that killed Warner are on the rise—and health officials warn that lethal infections will become more widespread unless the health care community takes aggressive action. Fueled in part by the overuse and misuse of antibiotics, drug-resistant germs cause more than 2 million illnesses and kill at least 23,000 Americans every year, according to the Centers for Disease Control and Prevention (CDC). Cases of Klebsiella pneumoniae carbapenemase (KPC), the most common type of CRE, have increased sevenfold over the past decade.

With a shrinking arsenal of antibiotics to combat these virulent infections, and a scarcity of new drugs in the development pipeline, health care officials warn that superbugs could lead to a global crisis. At the rate things are going, superbugs could kill 10 million people a year worldwide by 2050, according to one recent report on antimicrobial resistance backed by the British government.

The good news is that infection control experts say there is still time to act. Edward Septimus, MD, the medical director of infection prevention and epidemiology at HCA and a professor at Texas A&M Medical School, told attendees of last year’s international Infection Prevention Society (IPS) conference that the world is at a “tipping point.” With proper infection prevention strategies and better antimicrobial stewardship, he says, it’s still possible to slow the spread of supergerms, but “if we don’t take these warning signs seriously, we are going to be headed into a full-blown crisis.”

With that in mind, here’s a look at the three antibiotic-resistant pathogens that the CDC has classified as the most “urgent threats” and information on what nurses can do to help combat the problem.

Carbapenem-resistant Enterobacteriaceae (CRE)superbug CRE

The Threat: This so-called “nightmare” bug is not just one germ, but actually several different strains of bacteria within the Enterobacteriaceae family, which live in the gut. What all CREs have in commonand what makes them different from “normal” species of Enterobacteriaceaeis that they are resistant to carbapenems, powerful antibiotics generally reserved as “last-line” agents for the gravely ill. This leaves clinicians with few options in treating such infections. Symptoms vary, but CRE can cause sepsis, pneumonia, meningitis, and urinary tract and wound infections. Immunocompromised patients, and those being treated with invasive devices, such as central lines, urinary catheters, and mechanical ventilation, are more susceptible to illness.

Danger Zones: While CRE has been reported in most states, the pathogenat least for nowis mostly confined to acute care hospital settings. Long-term acute care facilities are especially good at incubating the microbe. During the first half of 2012, 4% of short stay-hospitals reported a CRE infection, compared to 18% of long-term facilities, according to a 2013 CDC Morbidity and Mortality Weekly Report. Several CRE outbreaks around the country have been traced to a contaminated duodenoscope used in an endoscopic retrograde cholangiopancreatography (ERCP) procedure, which is used to diagnose and treat problems in the pancreas and bile ducts. Rooms of infected patients are also a breeding ground for CRE. The most contaminated areas include bedside tables, infusion pumps, and sheet surfaces that surround a patient’s pillow, legs and “crotch,” according to a 2013 study in the Journal of Clinical Microbiology.

What You Can Do:  Hand hygiene is the number one way to prevent CRE infections and personal protective equipment should be used when caring for patients. Identifying infected patients early is also key. Hospitals should take pre-emptive precautions for patients transferred from high-risk facilities—and once a patient is found to have CRE, contact precautions should be initiated. Ideally, patients should be isolated in a single room. If that’s not possible, patients and staff should be “cohorted” to reduce the risk of transmission. There’s also growing evidence that bathing CRE-positive patients with antiseptic washes like Chlorhexidine can reduce contamination.

Clostridium difficile (C. difficile)

superbug C. difficile

The Threat:  This aggressive intestinal bug causes half a million infections in the United States each year and is responsible for one-third of all health care infections, according to the CDC. Toxins produced by C. difficile damage the lining of the intestine and lead to explosive and watery diarrhea. Older age, recent antibiotic use, and immune system dysfunction are all risk factors for developing C. difficile. The infection can be stubbornly difficult to eradicate and relapses are common.

Danger Zones: While some infections are occurring in the community, the vast majority of cases are contracted in health care facilities. Studies have shown that the hearty C. difficile spores can persist for up to five months on hard surfaces in hospital rooms. Hot spots for contamination include floors and bedrails—but windowsills, toilets, call buttons, telephones, and other objects also harbor the germ. C. difficile spores are often spread to other patients on the hands of nurses and other health care providers.

What You Can Do: Frequent handwashing with soap and water is the number one way to reduce the spread of C. difficile, as alcohol-based hand sanitizers DO NOT kill the bug. Patients should also be placed on contact precautions in single rooms. All visitors and caretakers should wear disposable gloves and gowns when entering a patient’s room, according to the CDC, and rooms should be cleaned daily with bleach or another EPA-approved spore-killing disinfectant.

Neisseria gonorrhoeae (N. gonorrhoeae)superbug N. gonorrhoeae

The Threat: In 2006, there were five different treatment options for this common sexually transmitted disease. Today, the CDC warns, there is only one effective class of antibiotics left to treat gonorrhea—the cephalosporins—and new strains emerging in Japan, England, and other countries have proved to be impervious even to those treatments. Currently, the CDC recommends dual therapy for patients—an oral dose of azithromycin and single shot of ceftriaxone—and it is still “highly effective” here in the United States. Gonorrhea can be insidious, though, and women, in particular, may be asymptomatic. When symptoms do occur, they may experience vaginal discharge, abdominal pain, and painful urination. Men frequently present with burning pain upon urination and a purulent urethral discharge. Infection can also occur in throat and rectum.

Danger Zones:  Unlike the other two pathogens mentioned in this article, drug-resistant gonorrhea is flourishing in the community—not the hospital. While anyone sexually active is at risk, gonorrhea is common among younger people, between 15 and 24 years of age, and disproportionately affects racial and ethnic minorities as well as men who have sex with men (MSM).

What You Can Do:  Candy Hadsall, RN, MA, an STD nurse specialist with the Minnesota Department of Health, says the most important thing nurses can do is stay up to date on the latest CDC treatment guidelines and share the information with their colleagues. Infections should be treated right away with the two medications listed above—and treatment of sexual partners is also a top priority. More than three dozen states, including Minnesota, also provide “expedited partner therapy,” which allows providers to send patients home with a prescription to treat their sexual partners, though it’s still best for individuals to see a clinician so they can receive the IM injection that is most effective in curing the infection. Be sure to instruct patients to complete the entire prescription and to return for retesting by culture and antibiotic susceptibility testing if symptoms persist. Treatment failures should be reported to the health department. Sexually active MSM and women with new and/or multiple partners, or a partner with an STD, should be tested at least once a year for gonorrhea.

What Every Nurse Needs To Know About Pain Management

What Every Nurse Needs To Know About Pain Management

The patient who watches the clock and requests their pain medication at the top of hour. The patient who always rates their pain a “10” out of 10. The patient who requests a specific narcotic like Dilaudid. Some nurses might view such behavior as red flags and will label those patients as potential “drug seekers”—but pain management experts like Bobbie Norris, BSN, RN, CNRN, BC-RN, a pain resource nurse at Johns Hopkins Department of Neurology and Neurosurgery in Maryland, says nurses who jump to those conclusions are often wrong and do a disservice to their patients.

The patient specifically asking for Dilaudid, for instance, isn’t necessarily an addict. In fact, a patient returning to the hospital for his umpteenth surgery most likely is an expert on what medications work best for him. “Just because a patient knows what works for them, that doesn’t mean they’re drug-seeking,” says Norris.

Susan McMillan, PhD, ARNP, FAAN, a nursing professor at the University of South Florida who has researched pain in oncology patients, echoes Norris’ concerns. “Nurses today are very concerned about drug-seeking,” she says, recalling a study in which nurses were asked what made them decide if a patient was “drug-seeking,” as opposed to suffering. “Their answers were: ‘If their pain was unrelieved, if it’s overwhelming, or if they ask too frequently,’” says McMillan, though in reality, each of those behaviors is an indicator that a patient’s pain is not being well managed.

Indeed, if Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are an effective measurement, patients are not getting enough pain relief during their hospital stays. According to HCAHPS patient survey data, only 71% of those surveyed said their pain was “always” well controlled in 2014-2015. Other studies, meanwhile, show that pain is often undertreated in pediatric patients, in older adults in long-term care, and among certain minority populations.

Experts believe the highly publicized global epidemic of opiod abuse is likely contributing to the conundrum. Nurses and other members of the health care team may worry about patient addiction and tolerance. Patients, too, often worry about addiction and side effects. As a consequence, some are reluctant to take pain medications or even report their pain.

Unrelieved pain, however, can cause serious problems and ultimately jeopardize an individual’s recovery from surgery or illness. Patients with poorly controlled pain are less likely to walk around and breath deeply, increasing their risk for atelectasis and other complications of immobility. Not addressing a patient’s pain also opens a nurse up to legal liability.

Experts say that nurses can better serve their patients by following these five strategies:

1. Believe Your Patient

Margo McCaffrey transformed the nursing profession’s approach to pain management when she declared in 1968 that pain is “whatever the experiencing person says it is, existing whenever he says it does.” While that’s the prevailing philosophy nurses learn in school, it doesn’t always carry over into clinical practice. “Nurses will say to me, ‘They can’t be in this much pain. Their blood pressure’s not up. They’re not tachycardic, they’re not tachypneic,’” says Norris. In fact, patients who’ve suffered from chronic pain for many years often show no objective systemic signs of distress because their central nervous system has “autoregulated.” While the risk of addiction is a valid concern, it does not negate the RN’s responsibility to accept the patient’s report of pain and respond to it with compassion and prompt intervention.

2. Better Monitoring

Measuring pain is an integral part of managing it. That’s why the VA developed an initiative in the 1990s to promote pain as the “fifth vital sign.” The concept of measuring pain as a vital sign—along with heart rate and blood pressure—was intended to get health care professionals in the habit of routinely screening, assessing, and documenting pain levels. One area where nurses continue to struggle, though, is with pain reassessment post-intervention. While every hospital has its own policies about when to reassess pain, ideally pain should be reevaluated at around the time it takes for a drug to reach its peak effect: that’s about 15 to 20 minutes after an IV bolus of morphine, and 60 to 90 minutes after an oral narcotic. Close monitoring also allows the RN to keep an eye on a patient’s sedation level and respiratory status and make any necessary adjustments to the patient’s treatment plan—and that should ease the anxiety of the RN who is worried about overmedicating their patient.

3. Expanding Therapies

Multimodal pharmacology is the optimal approach to managing pain. This means patients do better if they receive a combination of pain medications targeting different pain pathways, such as a narcotic pain reliever that directly decreases transmission of pain signals to the brain—and an NSAID to reduce swelling and inflammation at the site of injury. Drugs aren’t the only way to combat pain. Sandra Siedlecki, PhD, RN, CNS, a senior nurse scientist at Cleveland Clinic, has found that music therapy can be an effective tool to reduce chronic pain, which is notoriously difficult to treat. In fact, when patients suffering from chronic neck, back, and arm pain listened to an hour of music each day, their pain dropped by about 21% according to Siedlecki’s study published in the Journal of Advanced Nursing. A number of hospitals, including Johns Hopkins, have also introduced “Pain Control and Comfort” menus offering patients ‘a la carte’ therapies, ranging from warm packs and icepacks, to handheld fans, repositioning, stress balls, and handheld massagers. While many of the items on the menu have always been available, presenting them in this format gives the patients a feeling of “empowerment,” says Suzanne Nesbit, PharmD, CPE, a clinical pharmacy specialist and pain management research associate at Johns Hopkins.

4. A Tailored Approach

Patients don’t just differ in how they feel pain—they also differ in their response to pain medications. For example, studies have shown that approximately one-third of patients with cancer-related pain don’t respond well to morphine and develop intolerable adverse effects or fail to get any significant pain relief. Researchers, however, are beginning to unravel some of the mysteries of pain and providing scientific explanations for idiosyncrasies in drug response. Genetic variability in the cytochrome P450 (CYP450) system, the enzyme system in the liver that breaks down medications, can dramatically influence how well a drug works. If a CYP450 enzyme metabolizes a medication too quickly, for instance, the patient might require a higher dose for effective pain relief. If the patient’s CYP450 system is sluggish, they might require a smaller dose, otherwise toxicity can occur. Age, gender, and lifestyle can also impact drug response. In the future, hospitals will use genetic testing to help personally tailor pain treatment regimens for patients. Until then, nurses will have to rely on their assessment skills and clinical judgment to implement pain interventions adapted to each patient’s needs.

5. Examine Bias

Research has shown that ethnic minorities are routinely and systemically undertreated for pain when compared to white patients. One study by researchers at Emory University found that 43% of African American patients presenting at an Atlanta emergency department with long bone fractures received no pain medications. By contrast, only 26% of white patients with the same injuries “went untreated for pain.” A 2015 study published in JAMA Pediatrics found that black children with appendicitis were 20% less likely than white children to receive painkillers in the ED. A 2016 study by the University of Virginia on the topic attributed the disparate treatment to erroneous beliefs about biological differences among the two races. Awareness and acknowledgment that such bias exists is a first step to rooting out unconscious bias. The Joint Commission also recommends health care providers perform “teach back,” utilize educational and training techniques to “de-bias” care, and “assiduously” practice evidence-based medicine.

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