A Contextual Analysis to Explore Barriers and Facilitators of Pain Management in Swiss Nursing Homes

As part of a contextual analysis, this study aimed to generate a comprehensive understanding of barriers and facilitators to pain management in nursing homes to identify potential leverage points for future implementation studies. An explanatory sequential mixed-methods study embedded in a cross-sectional study in 20 Swiss nursing homes (data collection: July-December 2016). Quantitative data were collected via care worker questionnaire surveys comprising 20 items assessing perceptions of barriers to pain management. Descriptive statistics were computed. In the subsequent qualitative strand we conducted four focus group discussions with care workers (registered nurses, licensed practical nurses, and nursing aides) using a knowledge-mapping approach. Findings of both strands were merged and mapped onto domains of the Capability, Opportunity, and Motivation determine Behavior (COM-B) system, a model for behavior, to identify determinants for behavior change. Data from 343 completed care worker surveys (response rate 67.3%) and four focus groups with care workers were analyzed. Items rated most problematic were as follows: lack of availability of nonpharmacological treatment (60.9%), lack of application of nonpharmacological treatment (53.6%), reluctance of residents to report pain (51.1%), and lack of time for a comprehensive pain assessment (50.5%). Focus groups partly corroborated quantitative findings and complemented them with facilitators, such as close collaboration with physicians and further barriers (e.g., organizational factors such as high turnover and a lack of established routines in pain management). Our approach using a behavioral model highlighted a need for implementation strategies that improve pain management knowledge and focus on motivational aspects to establish new routines and habits related to pain management among care workers. Our findings suggest that future approaches to improve pain management in nursing homes should go beyond provision of education and training. To establish new practices or adapt existing ones, a more complex approach (e.g., introduction of external or internal facilitators) is necessary to influence motivation and ultimately change behavior

Boosting open-label placebo effects in acute induced pain in healthy adults (BOLPAP-study): study protocol of a randomized controlled trial

IntroductionPain is a highly prevalent symptom in the hospital setting, but treatment options remain limited. Harnessing the placebo effect in an ethical manner could provide a new possibility to reduce pain in clinical practice. So called open-label placebos (OLP) have been shown to elicit significant effects in reducing acute pain. But, before implementation, more knowledge concerning the properties of OLPs is needed. This study aims to assess the duration of analgesic effects from OLP and to determine the possibility of boosting such effects.Methods and analysisThis is the protocol of an ongoing (first patient enrolled in March 2023) single-site randomized trial investigating OLPs in two parts (i.e., substudies). In both parts, pain will be induced in healthy adults using an intradermal electrical stimulation model. Participants in Part 1 will have two study visits: An interventional visit with one OLP injection accompanied by an evidence-based treatment rationale and a control visit with no treatment. For Part 2, participants will be randomized into three groups: (1) A fixed-time “Booster” group including one single repetition of the OLP injection at a fixed time point, (2) an on-demand “Booster” group including one single repetition of the OLP injection on-demand, and (3) a control group who will receive just one OLP injection. Differences in pain ratings over time (using the Numeric Rating Scale) will be analyzed with several two-sample t-tests. The time point for a fixed-time “Booster” in Part 2 will be derived from Part 1 with additional statistical tools such as a broken-stick mixed-effect model.DiscussionThis study aims to further characterize the analgesic effects of OLPs. In doing so, it will provide valuable information needed for later implementation of OLPs in clinical practice, where they could play a role in multimodal analgesic concepts.Ethics and disseminationThe “Ethikkommission Nordwest- und Zentralschweiz” (BASEC 2023-00296) approved the study protocol. Results of the analysis will be submitted for publication in a peer-reviewed journal.Clinical Trial RegistrationThis study is registered at ClinicalTrials.gov (NCT05819476) and is listed in the Swiss National Registry at kofam.ch (SNCTP000005470)

Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis

BACKGROUND: To determine infection rate with use of epidural catheters in place for seven days or more. METHODS: Systematic review and pooled analysis of observational studies. RESULTS: Twelve studies with 4,628 patients (median 197 patients) provided information, of which nine (4,334 patients) were published after 1990. Eight studies (3,893 patients) were retrospective, and four studies (735 patients) prospective. Electronic searches identified three studies and searching reference lists nine. There were 257 catheter-related infections in total, of which 211 were superficial and 57 deep, giving rates of 6.1%, 4.6% and 1.2% respectively. Ten of the 12 studies had deep infection rates of 2% or less. The incidence of deep infection was 1 per 2391 days of treatment, or 0.4 per 1000 catheter treatment days. In nine studies (1503 patients), predominantly in cancer, and with average catheter duration of 74 days, the deep infection rate was 2.8%. The proportion of patients with infection of any type was higher in cancer patients with longer catheter duration. Limited numbers of events meant that no reliable estimate of the impact of prospective and retrospective design could be made. There appeared to be a relationship between catheter duration and infection rate from this and other recent estimates. Four of 57 (7%) patients with deep infection died. CONCLUSION: The best estimate is that one person in 35 with an epidural catheter in place for 74 days for relief of cancer pain can be expected to have a deep epidural infection, and that about 1 in 500 may die of infection-related causes. This is a most uncertain estimate given the limited nature of the evidence

Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis

BACKGROUND: Epidural anaesthesia is used extensively for cardiothoracic and vascular surgery in some centres, but not in others, with argument over the safety of the technique in patients who are usually extensively anticoagulated before, during, and after surgery. The principle concern is bleeding in the epidural space, leading to transient or persistent neurological problems. METHODS: We performed an extensive systematic review to find published cohorts of use of epidural catheters during vascular, cardiac, and thoracic surgery, using electronic searching, hand searching, and reference lists of retrieved articles. RESULTS: Twelve studies included 14,105 patients, of whom 5,026 (36%) had vascular surgery, 4,971 (35%) cardiac surgery, and 4,108 (29%) thoracic surgery. There were no cases of epidural haematoma, giving maximum risks following epidural anaesthesia in cardiac, thoracic, and vascular surgery of 1 in 1,700, 1 in 1,400 and 1 in 1,700 respectively. In all these surgery types combined the maximum expected rate would be 1 in 4,700. In all these patients combined there were eight cases of transient neurological injury, a rate of 1 in 1,700 (95% confidence interval 1 in 3,300 to 1 in 850). There were no cases of persistent neurological injury (maximum expected rate 1 in 4,600). CONCLUSION: These estimates for cardiothoracic epidural anaesthesia should be the worst case. Limitations are inadequate denominators for different types of surgery in anticoagulated cardiothoracic or vascular patients more at risk of bleeding

Language difficulties in outpatients and their impact on a chronic pain unit in Northwest Switzerland

Many foreign patients attending our pain clinic are unable to understand one of the four Swiss national languages and are also unable to speak English. Therefore, communication with these patients can be very difficult or even impossible. Consequently, diagnosis and treatment may also prove difficult. Recognizing that language barriers can have deleterious effects, the use of an interpreter is at times the only way to communicate, however, the financial responsibility becomes that of the health care provider

Association between intra-operative fentanyl dosing and postoperative nausea/vomiting and pain A prospective cohort study

BACKGROUND Postoperative nausea and/or vomiting (PONV) is one of the anaesthesia-related effects most dreaded by patients and may delay hospital discharge. Although scores and risk factors are established, many were developed before contemporary anaesthesia regimens and without focussing on modifiable anaesthesia-related variables. OBJECTIVE To examine whether, in association with a contemporary anaesthesia regimen, there is an association between intra-operative fentanyl dose and PONV, and, second, postoperative pain within the first 24 h. DESIGN Prospective, observational cohort. SETTING Single-centre university hospital. PATIENTS Inclusion criteria were opioid-naive patients without chronic pain and with a simplified Apfel score at least 2 undergoing abdominal, gynaecological or otorhinolaryngological inpatient surgery. INTERVENTION None. MAIN OUTCOME MEASURE With logistic regression, we examined three models of increasing complexity exploring the relationship between PONV and fentanyl dosing: Model 1, simplified Apfel score + intra-operative fentanyl; Model 2, Model 1 + pre-emptive antiemetic prophylaxis; Model 3, Model 2 + postoperative morphine. Model 1 was the primary analysis. Second, we explored whether or not postoperative pain scores were associated with intra-operative fentanyl dosing. RESULTS From the 363 patients, 163 (45%) experienced PONV, despite the use of total intravenous anaesthesia with propofol in more than 80% of the cohort, and some 66% of patients receiving additional antiemetic agents. After adjusting for the simplified Apfel score, higher intra-operative fentanyl dose was associated with PONV: odds ratio per mu g h(-1), 1.006 [95% confidence interval (CI) 1.002 to 1.010]. Including intra-operative fentanyl in the simplified Apfel score also increased the area under the receiver operator characteristics curve [0.601 (95% CI 0.555 to 0.662) vs. 0.651 (95% CI 0.594 to 0.707); P = 0.016]. Finally, a higher intra-operative fentanyl dose was associated with higher 24 h pain scores (P = 0.001) and a trend towards higher 24 h morphine requirements (P = 0.055). CONCLUSION Even when using propofol and antiemetic agents, PONV within the first 24 h remained higher than expected. Intra-operative fentanyl, a modifiable risk factor, is associated with the incidence of PONV and postoperative pain

Pain Management in Nursing Home Residents: Findings from a Pilot Effectiveness-Implementation Study

OBJECTIVES: To evaluate the effectiveness and implementation of a multilevel pain management intervention in nursing homes (NHs) comprising a pain management guideline, care worker training, and pain champions.DESIGN: An implementation science pilot study using a quasi-experimental effectiveness-implementation (hybrid II) design.SETTING: Four NHs in Switzerland.PARTICIPANTS: All consenting long-term residents aged 65years and older with pain at baseline (N = 62) and all registered and licensed practical nurses (N = 61).INTERVENTION: Implementation of a contextually adapted pain management guideline, interactive training workshops for all care workers, and specifically trained pain champions.MEASUREMENTS: Interference from pain, worst and average pain intensity over the previous 24hours; proxy ratings of pain with the Pain Assessment in Advanced Dementia scale; and care workers' appraisal of the guideline's reach, acceptability, and adoption.RESULTS: Pain-related outcomes improved for self-reporting residents (n = 43) and residents with proxy rating (n = 19). Significant improvements of average pain from baseline to T1 (P = .006), and in worst pain from baseline to T1 (P = .003) and T2 (P = .004). No significant changes in interference from pain (P = .18). With regard to the implementation efforts, about 76% of care workers indicated they were familiar with the guideline; 70.4% agreed that the guideline is practical and matches their ideas of good pain assessment (75.9%) and treatment (79.7%).CONCLUSION: Implementation of a multilevel pain management intervention did significantly improve average and worst pain intensity in NH residents. However, to effect clinical meaningful changes in interference from pain, a more comprehensive approach involving other disciplines may be necessary.© 2019 The American Geriatrics Society

Serious complications associated with external intrathecal catheters used in cancer pain patients : a systematic review and meta-analysis

BACKGROUND: Potential risks of intrathecal catheters in cancer patients include infection, bleeding, and neurologic injury. METHODS: A systematic review and a pooled analysis of observational studies were performed. Articles reporting on adverse events (infections, bleeding, granuloma, and death) associated with intrathecal catheters and external pumps in cancer patients were identified. Electronic searches of PubMed, MEDLINE, and EMBASE were conducted. Observations from different studies were pooled using a generalized mixed-effect model. Model estimates and their standard errors (SEs) were used for calculating 95% confidence intervals (CIs) on the overall proportion. RESULTS: The analysis identified 10 articles, including a total of 821 patients. Twenty catheter-related infections were identified. Of these, 10 were superficial and 10 were deep infections, with rates of 2.3% (95% CI, 0.8-6.1) and 1.4% (95% CI, 0.5-3.8), respectively. Furthermore, the authors calculated that every 71st patient had a deep infection after an average catheter duration of 54 days. The risk of bleeding was found to be 0.9% (95% CI, 0-2.0), and for neurologic injury 0.4% (95% CI, 0-1.0). The infection rates are comparable to other intrathecal catheter techniques. CONCLUSIONS: Serious complications are rare in both hospitalized and homebound patients with intrathecal catheters. This analysis supports the reasoning that the potential benefit of intrathecal catheters in the treatment of severe cancer pain is likely to outweigh the potential for serious complications associated with this technique. Therefore, an external intrathecal catheter can be considered an effective and low-cost solution for the control of pain in such patients

Tropisetron blocks analgesic action of acetaminophen : a human pain model study

Because the mechanism underlying the analgesic action of acetaminophen remains unclear, we investigated the possible interaction of acetaminophen with central serotonergic pathways. The effects of acetaminophen, tropisetron, the combination of both drugs, and saline on pain perception and central sensitization in healthy volunteers were compared. Sixteen healthy volunteers were included in this randomized, double-blind, placebo-controlled crossover study. Intracutaneous electrical stimulation (46.1 ± 19.1 mA) induced acute pain (numeric rating scale, 6 of 10) and stable areas of hyperalgesia and allodynia. Pain intensities and areas of hyperalgesia and allodynia were regularly assessed before, during, and after a 15-min infusion of acetaminophen, tropisetron, the combination of both drugs, and saline. Acetaminophen concentrations were measured to rule out any pharmacokinetic interaction. Both acetaminophen and tropisetron led to decreased pain ratings as compared to saline. However, when acetaminophen and tropisetron were administered simultaneously, the pain ratings were not affected. There was no significant difference in the evolution of the hyperalgesic and allodynic areas during the study period between the study groups (P = .06 and P = .33, respectively). Acetaminophen serum levels were not significantly different when associated with tropisetron (P = .063), although we observed a trend toward lower acetaminophen concentrations when both drugs were concurrently administered. In summary, while the combination of acetaminophen and tropisetron showed no analgesic action, each drug administered alone led to decreased pain ratings as compared to saline. In an electrically evoked human pain model, the combination of acetaminophen with tropisetron was free of any analgesic potential. However, when administered on its own, both acetaminophen and tropisetron were mildly analgesic