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

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

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


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