Current Developments in Intraspinal Agents for Cancer and Noncancer Pain

Since the late 1980s, intrathecal (IT) analgesic therapy has improved, and implantable IT drug delivery devices have become increasingly sophisticated. Physicians and patients now have myriad more options for agents and their combination, as well as for refining their delivery. As recently as 2007, The Polyanalgesic Consensus Conference of expert panelists updated its algorithm for drug selection in IT polyanalgesia. We review this algorithm and the emerging therapy included. This article provides an update on newly approved as well as emerging IT agents and the advances in technology for their delivery

Improving Patients\u27 Pain Management Through Proper Documentation

The aim of this project was to improve pain documentation on the Surgical Unit as a means to enhance caregiver communication on finding the best methods to manage patients’ pain. Effectively managing patients’ pain leads to better patient outcomes, increased patient and nurse satisfaction, and decreased length of hospitalization. The setting is a not-for-profit hospital in Southern California. The microsystem selected is the 32-bed capacity Surgical Unit that mainly admits pre- and post-surgical patients, but also accommodates non-surgical, telemetry, and trauma cases. To improve pain assessment documentation, collaboration was sought with the multidisciplinary team (IT department, clinical nurse specialists, and a nursing task force), to create an easier way for nurses to document a pain assessment with each administration of a pain medication. Initiating changes to the eMAR began late February 2016 and presented to the Surgical Unit staff during the first week of March 2016. Prior to implementation, chart audits were performed between January to February 2016 and found that assessments were only being performed 80% of the time. Changes to the methods of documentation in the eMAR, staff in-services, and the distribution of educational materials has raised compliance to 87%. Sustainability is expected to prevail as the intervention has stakeholder support, is in line with the institution’s procedures, and has perceived benefits from staff members

Master of Science

thesisThough medical advances in the last century now allow us to forestall death, many patients suffer from significant symptoms as they battle severe disease. Opioid medications are particularly effective when treating pain in these patients and infusion by the patient controlled analgesia (PCA) paradigm is commonly used in patients with severe disease. While PCA allows rapid titration yet individualized adjustment of opioid dose, it involves complex, high-stakes decisions. Unfortunately, clinicians complain that it is often difficult or impossible to find the data needed to make these decisions. A relevant data display could support clinical decisions by providing real-time up-to-date clinical data at the point of care. Literature synthesis and multiple modeling techniques were used to quantify the domain. An inductive, qualitative approach, including graphical mapping techniques, was used to build a foundational domain information model which was subsequently validated using a survey of domain experts. A gap analysis was performed, mapping concepts from the information model to the emerging HL7 FHIR standard. Modeling revealed a complex workflow, highlighted the bottleneck in information flow to providers at the point of care, and supported the premise that a relevant data display would be beneficial. The gap analysis showed that currently existing FHIR resources are capable of representing all relevant concepts from the domain information model needed for decision making in this complex use-case. Potential problems with FHIR implementation were identified and recommendations to address these are presented

A development and assurance process for Medical Application Platform apps

Doctor of PhilosophyDepartment of Computing and Information SciencesJohn M. HatcliffMedical devices have traditionally been designed, built, and certified for use as monolithic units. A new vision of "Medical Application Platforms" (MAPs) is emerging that would enable compositional medical systems to be instantiated at the point of care from a collection of trusted components. This work details efforts to create a development environment for applications that run on these MAPs. The first contribution of this effort is a language and code generator that can be used to model and implement MAP applications. The language is a subset of the Architecture, Analysis and Design Language (AADL) that has been tailored to the platform-based environment of MAPs. Accompanying the language is software tooling that provides automated code generation targeting an existing MAP implementation. The second contribution is a new hazard analysis process called the Systematic Analysis of Faults and Errors (SAFE). SAFE is a modified version of the previously-existing System Theoretic Process Analysis (STPA), that has been made more rigorous, partially compositional, and easier. SAFE is not a replacement for STPA, however, rather it more effectively analyzes the hardware- and software-based elements of a full safety-critical system. SAFE has both manual and tool-assisted formats; the latter consists of AADL annotations that are designed to be used with the language subset from the first contribution. An automated report generator has also been implemented to accelerate the hazard analysis process. Third, this work examines how, independent of its place in the system hierarchy or the precise configuration of its environment, a component may contribute to the safety (or lack thereof) of an entire system. Based on this, we propose a reference model which generalizes notions of harm and the role of components in their environment so that they can be applied to components either in isolation or as part of a complete system. Connections between these formalisms and existing approaches for system composition and fault propagation are also established. This dissertation presents these contributions along with a review of relevant literature, evaluation of the SAFE process, and concludes with discussion of potential future work

Fentanyl Administration on Emergence From Surgery and Post Anesthesia Care Unit Discharge Times and Pain Scores

Problem: Pain has been historically mismanaged potentially leading to a host of negative physiological consequences. Today’s dynamic health care reform offers an opportunity to increase satisfaction with care. Utilizing the PICO question, in adults undergoing laparoscopic cholecystectomy over a 12 month period, does medication with fentanyl during emergence versus not medicating during emergence reduce the need for pain medications and discharge times? Evidence/Background: Two national studies surveyed patient perception of pain management following surgery. The first, conducted by Apfelbaum et.al (2003) showed that 80% of patients experienced acute pain after surgery with 86% rating that pain as moderate to severe or extreme. The second national survey, by Tong et.al (2014) showed similar results with 86% experiencing pain following surgery and 76% rating that pain as moderate to severe. Despite standards released in 2001 by Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and recommendations by the American Society of Anesthesiologist Task Force on Pain Management more needs to be done. Strategy: A quantitative retrospective chart review was used to evaluate patients between the age of 19-60 who underwent a laparoscopic cholecystectomy surgery who either received fentanyl on emergence or did not receive fentanyl on emergence from surgery. A convenience sample of 503 charts were obtained with 256 charts being excluded from the study. The remaining 247 charts were included in the study with 170 not given fentanyl and 77 given fentanyl. A systematic random sample (k = N/n) was obtained from the remaining charts. An independent samples t-test analyzed the group differences of administering fentanyl on emergence on the following: (a) PACU length of stay, (b) time to first analgesic administration in PACU, and (c) how much morphine was given in PACU. Results: An independent samples T-test showed no statistically significant outcomes related to giving fentanyl on emergence on the following: (a) PACU total length of stay (p = 0.066), (b) the time to first analgesic administration in PACU (p = 0.172) or (c) the amount of morphine given in PACU (p = 0.080) versus those who did not receive fentanyl

Advancing Pharmacist Collaborative Care within Academic Health Systems.

INTRODUCTION:The scope of pharmacy practice has evolved over the last few decades to focus on the optimization of medication therapy. Despite this positive impact, the lack of reimbursement remains a significant barrier to the implementation of innovative pharmacist practice models. SUMMARY:We describe the successful development, implementation and outcomes of three types of pharmacist collaborative care models: (1) a pharmacist with physician oversight, (2) pharmacist-interprofessional teams and (3) physician-pharmacist teams. The outcome measurement of these pharmacist care models varied from the design phase to patient volume measurement and to comprehensive quality dashboards. All of these practice models have been successfully funded by affiliated health systems or grants. CONCLUSIONS:The expansion of pharmacist services delivered by clinical faculty has several benefits to affiliated health systems: (1) significant improvements in patient care quality, (2) access to experts in specialty areas, and (3) the dissemination of outcomes with national and international recognition, increasing the visibility of the health system

Nurses\u27 Perceptions of the Pharmacological Management of Acute Pain Experienced by Patients Hospitalised in the General Ward Setting

This study explored and described the experiences and perceptions of nurses managing acute pain in a Western Australian public hospital. The focus was nurses practising in the general ward setting and using current prescribing guidelines. The aim of this research was to explore nurses\u27 attitudes, beliefs and knowledge about pain and pain pharmacology and how this practice setting influences efficient pain management. Qualitative methodology was selected for its ability to explore complex issues in order to build nursing knowledge and guide nursing practice. This study used a descriptive, exploratory design based on a phenomenological approach. The sample comprised ten Registered Nurses who were working on general surgical wards in an acute care public hospital. Data were collected from tape recorded semi-structured interviews. Analysis encompassed transcription, coding and categorising of data that enabled concepts and themes to emerge. Nurses\u27 attitudes, beliefs and knowledge were examined. Nurses were found to accept the subjectivity of pain, to believe patients\u27 self reports of pain and to be generally supportive of numerical pain rating scales. Elderly patients and patients with a history of intravenous drug use were identified as groups that might be disadvantaged in regard to pain management in the general ward setting. Nurses\u27 roles as patient advocates and independent managers of pain at the bedside were highlighted and the lack of consistent pain management across nursing shills was identified as a problem that is potentially widespread. Continuing difficulties were acknowledged when analgesic medications were prescribed to be given as required, rather than on fixed time regimes. In recognition of this, nurses were supportive of the administration of regular analgesia. The hospital\u27s Acute Pain Service was perceived to be a valuable resource and non-pharmacological pain management strategies were recognised as an effective adjunct to analgesic medication and important to nurses\u27 independent practice. Effective pain management is a humane response to suffering, as well as being cost-effective for the health system in terms of reducing inpatient complications. This study provided an indication of current issues in acute pain management from the perspective of nurses in the ward setting. Implications for clinical practice and directions for future research are provided

Predictive modelling of Loss Of Consciousness under general anaesthesia

Treballs Finals de Grau d'Enginyeria Biomèdica. Facultat de Medicina i Ciències de la Salut. Universitat de Barcelona. Curs: 2021-2022. Director: Pedro L. Gambú

The pharmacological management of palliative care symptoms in haematology and oncology patients at Parirenyatwa Group of Hospitals (PGH) in Harare Zimbabwe

Introduction: Palliative care is the approach to the care of patients with life-threatening illnesses. An important part of this is the rational use of a pharmacological approach to relieve suffering by addressing the symptom burden of the patient. Palliative care symptoms contribute a great deal to the suffering of the patient and affects quality of life. Different studies across several countries on the palliative care symptoms have identified common symptoms with pain being the most frequent. The WHO Public Health Strategy for palliative care outlines four components: policy, education, implementation and drug availability. These components interlink and each one affects the others. The drugs used for palliative care symptoms should be classified as essential medicines and be available to all patients who need this treatment. Factors influencing the effective pharmacological management of palliative care symptoms include drug availability, policy and the approach of the prescribers. Studies have shown that developing countries rank low in the use of the essential palliative care drugs especially morphine. Aim: The aim of this study was to describe the prevalence of palliative care symptoms and the prescribing and administration patterns in oncology and haematology patients at PGH, as well as exploring the health workers' opinions on the pharmacological approach to these symptoms. Methods: A mixed method approach was used to qualitatively look at the health workers' responses using inductive thematic analysis and quantitatively obtain information on palliative care symptom management from the health workers and patient records. Results: Pain was the commonest palliative care symptom identified by health workers, and evident in the patient records. A list of other palliative care symptoms, and the frequency at which they occurred was compiled in this study. The health workers highlighted drug availability, palliative care education and need to engage some nurses in prescribing some of the palliative care drugs. Fewer than half of the patient records assessed as being in need of palliative care (N = 247) were given medications from the recognized palliative care drug list (N = 101). Conclusion: This study showed that essential medicines for palliative care symptoms are not easily available in Zimbabwe for various reasons that include cost, policy, education and training. Pain and other palliative care symptoms are not adequately managed. Therefore, palliative care is not yet integrated into the health care system in Zimbabwe as mandated by the WHO. Recommendations to improve palliative care symptom treatment are suggested