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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 3  |  Page : 166-171

Safely managing pain in hospitalized older adults: Implementation of a geriatric acute pain management order set


1 Department of Acute Pain Services, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
2 Department of Senior Care Services, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
3 Department of Educational Services, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
4 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

Date of Submission22-May-2021
Date of Acceptance28-Aug-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Ms. Heather L Alban
Department of Acute Pain Services, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_67_21

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  Abstract 


Introduction: Opioid pain medications carry serious risks when not used properly. Tools should be used to establish individualized, multimodal pain treatment plans that use opioids judiciously and effectively.This study aimed to explore outcomes of older adult patients who experience acute pain and determine if implementation of a Geriatric Acute Pain Management Order Set reduces opioid consumption during hospitalization, length of stay, unnecessary readmissions, and discharges to skilled nursing facilities.
Materials and Methods: This was a retrospective chart review over 12 months at a Level I trauma center.Implementation of Geriatric Acute Pain Management Order Set on adults ≥70 years admitted to services diagnosed with long bone, rib, vertebral, or pelvic fracture. Exploratory analysis using the order set was compared to standard pain management practices.
Results: Nonsignificant association was found between order set usage and average oral morphine equivalents (OMEs), consumption per day (P = 0.08), length of stay (P = 0.45), and number of days to readmission (P = 0.70). Hip/femur/pelvic fractures showed higher median OME/day (14.2 mg) compared to patients with humerus/scapula/clavicle fracture(s) (8.9 mg). Median OME/day was statistically different between types of service lines (P < 0.01), with orthopedics having the highest daily OME (30.4 mg). Most patients were discharged to skilled nursing facilities (n = 277) and homes (n = 114) with no demonstrated correlation between the amount of opioids consumed and discharge disposition.
Conclusions: Order set integration into practice guides safe and effective care of older adults experiencing pain. Optimization of pain management modalities in the hospital serves to restore mobility and function, reduce patient harm, and improve quality of life.
The following core competencies are addressed in this article: Practice-based learning and improvement, Patient care and procedural skills, and Systems-based practice.

Keywords: Multimodal pain management order set, older adults, opioids, pain, trauma


How to cite this article:
Alban HL, Krasa HE, Deringer PW, Kumar KN. Safely managing pain in hospitalized older adults: Implementation of a geriatric acute pain management order set. Int J Acad Med 2021;7:166-71

How to cite this URL:
Alban HL, Krasa HE, Deringer PW, Kumar KN. Safely managing pain in hospitalized older adults: Implementation of a geriatric acute pain management order set. Int J Acad Med [serial online] 2021 [cited 2021 Dec 2];7:166-71. Available from: https://www.ijam-web.org/text.asp?2021/7/3/166/326819




  Introduction Top


Older adults are often overmedicated secondary to inadequate medication adjustments/dose reductions or are undermedicated in fear of causing harm. The Geriatric Acute Pain Management Order Set was developed in response to the mismanagement of pain in older adults. An evaluation of a patient safety database from 2004 to 2013 revealed that 40% of medication errors were a result of failure to change default medication doses in the electronic health record (EHR); default dosing is often higher than the recommended safe older adult prescribing guidelines.[1] A standardized pain order set, inclusive of nonopioid and adjunct medications with safe dosing guidelines for older adults, can improve prescribing practices and ensure patient safety while providing appropriate analgesia. The aim of this study was to explore outcomes of older adult patients who experience acute pain as a result of injury and determine if implementation of a Geriatric Pain Management Order Set, as compared to standard pain management treatments, reduces opioid consumption during hospitalization, length of stay, unnecessary readmissions, and discharges to skilled nursing facilities.


  Materials and Methods Top


Participant characteristics

Sample included 464 patients (mean [standard deviation] =85 years + 7.6; 65.9% female [n = 306], 34.1% male [n = 158]); the patient demographics are summarized in [Table 1]. Hip/femur/pelvic fractures were most common (40.9%, n = 190), followed by vertebral (24.4%, n = 113), sternal/rib (16.6%, n = 77), and upper extremity fractures (9%, n = 42). About 9% (n = 42) were diagnosed with more than one type of fracture, median length of stay of stay = 44 (range 0–38). Approximately 8% of patients were readmitted to the hospital within 30 days of discharge (median number of days to readmission = 9). Average daily oral morphine equivalent (OME) ranged from 0 to 244.3 mg (median = 15.4 mg), which was similar between genders. The majority of patients (74%) had an OME <30 mg per day; only 10% required an OME >50 mg per day. Regarding service-line admission, 72.2% were admitted to trauma (n = 335), 26% to orthopedics (n = 121), and 1.7% to general surgery (n = 8). More than half of the sample (60%) were discharged to a skilled nursing facility (n = 277), 24.5% were discharged home (n = 114), and approximately 10% required acute rehabilitation (n = 49), with the remaining discharged to a higher level of care, hospice, or behavioral health.
Table 1: Patient demographics

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A total of 64/464 patients (13.8%) received a Geriatric Acute Pain Management Order Set. There was a nonsignificant association between OME and order set usage (P = 0.08). The order set group had a median OME of 12.9 mg (range 0-68.8mg), compared to 16.4 mg for the nonorder set group (range 0-244.4mg). In addition, there were nonsignificant differences based on order set usage/nonusage for length of stay (P = 0.45) and days to readmission (P = 0.70).

Methods

A retrospective chart review was conducted of all patients >70 years of age admitted at a Level I trauma center in the Northeastern United States over a 12-month period under a trauma, orthopedic, or surgical service with a diagnosis of long bone, rib, vertebral, or pelvic fracture(s). Our Institutional Review Board (IRB) approved the study. Data included age, gender, admission/discharge date, length of stay (number of days), type of fracture, admitting service line, discharge disposition (i.e., home, acute rehabilitation, long term nursing home placement, behavioral health, hospice), emergency department encounter date within 30 days post discharge, 30-day readmission to the hospital (yes/no), number of days to readmission, origination of medication orders (i.e., use of geriatric pain order set; yes/no) and average daily opioid consumption. The total amount of opioid consumed during hospitalization was divided by the number of days in the hospital and reported out in daily OME. Research conducted was a manual review of existing EHR data that were obtained and stored in a secure data warehouse platform for analysis.

An exploratory analysis was conducted comparing daily OME consumption based on order set usage versus standard pain medication prescribing. Additional subgroup analyses evaluated differences in OME based on the type of fracture, service line, discharge disposition, and 30-day readmissions. Due to the skewed distribution of OME consumption, Mann–Whitney and Kruskal–Wallis tests were conducted. Separate Chi-square tests were conducted for categorical outcomes. Data were analyzed using IBM SPSS for Windows Version 26 (Armonk, NY), with P < 0.05 denoting statistical significance and no adjustments for multiple comparisons.


  Results Top


Consequences of fractures

Patients with rib fractures have an increased risk of pneumonia, acute respiratory distress syndrome, transfer to intensive care, and mechanical ventilation which can prolong hospitalization and increase mortality.[2],[3],[4] Höch et al. identified a 2-year mortality rate of 30% in patients with operative and nonoperative pelvic fractures; in addition, other complications such as pulmonary embolism, pneumonia, and acute respiratory insufficiency prolonged hospitalization and negatively impacted quality of life.[5] Similarly, older adults with hip fractures carry a 20%–28% 1-year mortality rate or have a significant reduction in mobility and overall quality of life.[6]

Oral morphine equivalent use by type of fracture

The general distribution of OME use by fracture type was significantly different [P < 0.0001, [Table 2]]. Patients with hip/femur/pelvis fracture(s) had higher median OME/day usage (14.2 mg) versus patients with humerus/scapula/clavicle fracture(s) (8.9 mg). Post hoc analysis revealed the following significant between-group differences: (1) humerus/scapula/clavicle fracture versus hip/femur/pelvis fracture (P = .014); (2) vertebral fracture versus hip/femur/pelvis fracture (P < .01); and (3) sternum/rib fracture versus hip/femur/pelvis fracture (P = .007).
Table 2: Oral morphine equivalents consumption by type of fracture

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Oral morphine equivalent use by service line

The general distribution of OME use by service line type was significantly different [P < 0.01, [Table 3]], with orthopedic service having the highest median OME use per day (30.4 mg). Post hoc analyses revealed a significant difference between trauma and orthopedic service lines only (P < 0.01).
Table 3: Oral morphine equivalents consumption by service line

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Oral morphine equivalent use <30 mg or ≥30 mg and discharge to home

A total of 114 patients (24.5%) were discharged home (85 patients receiving < 30 mg OME [75.2%], 28 patients receiving > 30 mg OME [24.8%]). The association between OME categories and discharge to home was not significant (P = 0.7).

Oral morphine equivalent use by 30-day readmissions

The general distribution of OME use based on 30-day readmission was not significant (P = 0.6). In patients readmitted at 30 days, median OME use was 20 versus 15.4 mg in nonreadmitted patients.


  Discussion Top


Millions of older adults enter the health-care system with complaints of pain as a result of injury or illness. The incidence of geriatric trauma and related hospitalizations has escalated 18%–35% in the past decade with 20% of those patients requiring intensive care unit level of care.[7],[8] Falls represent the leading cause of injury and death in older adults. Severe pain is a predictable manifestation of fractures. Nociception and pain expression in older adults is physiologically impacted by decreases in acetylcholine, noradrenaline, serotonin, and gamma-aminobutyric acid, which leads to a reduced endogenous analgesic response, decreased number of peripheral nociceptive neurons, and an overall increased pain threshold.[9]

Older adults are often overmedicated secondary to inadequate medication adjustments/dose reductions or are undermedicated in fear of causing harm. Drug metabolism and elimination are prolonged due to slowed gastric emptying, decreased renal perfusion, and reduced hepatic function.[10] The distribution and half-life of medications increase due to age-related decline in renal function, reduced muscle mass, increased body fat, decreased cardiac output, and reduced levels of plasma proteins.[11] Older adults are more likely to experience opioid-related adverse events (e.g. respiratory depression, overdose, sedation, cognitive impairment, and constipation) due to drug accumulation and reduced medication clearance.[11],[12] Initial opioid dosing should be reduced by 25%–50% in the older adult population.[11],[12] Integrating opioid reduction strategies along with nonpharmacological treatment modalities significantly decreases the risk of adverse events and negative clinical outcomes.

The Geriatric Acute Pain Management Order Set was developed in response to the mismanagement of pain in older adults. An evaluation of a patient safety database from 2004 to 2013 revealed that 40% of medication errors were a result of failure to change default medication doses in the EHR; default dosing is often higher than the recommended safe older adult prescribing guidelines.[1] A standardized pain order set, inclusive of nonopioid and adjunct medications with safe dosing guidelines for older adults, can improve prescribing practices and ensure patient safety while providing appropriate analgesia.

Analyses revealed no significant difference in opioid consumption with the utilization of the order set. Low use of the order set may have contributed to the insignificant correlation. Physicians/advanced practitioners were extensively educated on proper utilization of the order set, pharmacology, and best practice guidelines for acute pain management in the older adult population; therefore, the number of times the order set was used may not be a true reflection of the benefits. Some prescribers felt that ordering lower doses or avoiding medications would not control pain effectively. Staffing turnover, new residents, and lack of provider buy-in may have negatively impacted the results.

Additional analysis showed that OME consumption was statistically different between the four different types of fractures studied (P > 0.0001). Patients with hip/femur/pelvic fractures had the highest OME consumption [Table 2] possibly due to extensive muscle and nerve innervation surrounding osseous structures.

Regarding service-line analysis, orthopedic patients consumed the highest number of OME/day [Table 3], which may be related to the types of fractures most typically seen by this service line (i.e. hip, femur, and pelvic). Trauma patients consumed fewer opioids with an overall lower average OME/day, despite this service caring for complex polytrauma cases. The reduction in opioid consumption is reflective of the trauma team receiving recurrent, extensive education on pain management modalities and being receptive to integration of the order set into daily workflow.

Additional analysis revealed no correlation between OME consumption and discharge disposition. The assumption prior to the study was that patients consuming more opioids would be more likely to be discharged to a nursing facility. There was also no significant correlation between <30 mg or >30 mg OME consumption and disposition to home. Best-practice standards recommend an OME <50 mg daily to ensure improved patient outcomes and mitigate harm. Opioid consumption exceeding 50 mg OME daily increases the risk of respiratory/central nervous system depression and fatal/nonfatal overdoses.[13]

Finally, the study analysis did not reveal a correlation between hospital OME consumption and readmissions within 30 days of discharge. Just as with disposition, confounding variables such as social determinants (family support, home conditions, and transportation), comorbid medical conditions, quality of transitional-care process, and functional ability of patient may have influenced the results.[14],[15]

The Geriatric Acute Pain Management Order Set highlights safe dosing for nonopioid pain medications while advising providers to avoid medications such as muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), and morphine. Topical agents and neuropathic medications were also included in the multimodal analgesic plan. The order set refers to low doses of opioids, only be prescribed if nonopioids have failed to control pain. In conjunction, orders were available for nonpharmacological treatments (e.g., heat/cold application, physical/occupational therapy, and spiritual counseling). Medications within the order set were organized to facilitate prescribing nonopioid and nonpharmacological treatments first. Extensive review of evidence-based research, national practice guidelines, and AGS Beers Criteria® guided the development of the order set.[16] This order set is unique, as it was the first of its kind within the other institutions utilizing the same EHR.

Optimization of pain control is an essential medical treatment strategy in patients with fractures. Opioid medications have been considered the mainstay for acute and chronic pain management across the United States for decades. Although effective in decreasing a person's perception of pain, opioids are not recommended as a first-line treatment in acute pain management and should be avoided in chronic pain management.[13],[17] Opioids have serious risks when not used properly, such as physical dependence, addiction, overdose, and death.

As pain is a foreseeable manifestation of trauma, managing acute pain with multimodal, nonopioid analgesics (i.e. acetaminophen, NSAIDS, alpha-2 agonists, antidepressants, antiepileptics, and N-methyl-D-aspartate antagonists) reduces the risk of opioid misuse, abuse, and patient harm.[18],[19] The Eastern Association for the Surgery of Trauma, Trauma Anesthesiology Society, and the Washington State Agency Medical Directors' Group recommend prescribing multimodal analgesia versus sole use of opioid therapy to optimize clinical outcomes and pain control.[20],[21] Multimodal pain modalities have shown to be opioid-sparing and work synergistically to produce superior pain control.[19]

Opioid-related adverse events contribute to higher health-care costs (approximately $22,077 vs $17,370) and prolonged hospitalization (7.6 vs 4.2 days).[22] Avoiding opioids in hospitalized, older adults reduced length of stay (5.2 vs. 7.7 days) and decreased readmission rates (19.6% vs. 25%); in addition, patients were more likely to be discharged home versus a skilled nursing facility.[23] Hospitalized patients discharged with an opioid prescription are more likely after 1 year to meet the criteria for chronic opioid use; the risk significantly increased in surgical patients requiring total hip replacement, total knee replacement, laparoscopic cholecystectomy, and open appendectomy.[24]

Future research is warranted to determine if pain management tools, such as standardized order sets, improve patient outcomes and enhance safety. Further exploration of opioid consumption in the hospital setting is needed to determine correlation with quality indicators such as discharge disposition and readmissions.

Limitations

A new EHR was integrated into the hospital system prior to the start of the research study which effected provider workflow during the transition. The electronic medication ordering system did not allow the Geriatric Pain Management Order Set to auto-populate on older adults; physicians/advanced practitioners had to manually search for the order set to use it in practice. Historical EHR data were not available; therefore, comparative patient information was not obtainable for analyses. The sample population was not randomized; all patients who met inclusion criteria were included in the research.


  Conclusions Top


Management of pain in older adults can be more complex compared to the general population due to an increasing number of medical comorbidities, polypharmacy, and changes in pharmacokinetics/pharmacodynamics that occur with aging. Customized order sets can be used to guide provider decision-making to ensure safe prescribing practices while attaining more effective pain control with appropriate multimodal pain regimens. Utilizing medication order sets allows providers to follow a stepwise approach to pain management, which will maximize pain control, avoid adverse medication effects, and improve patient and provider satisfaction.

Financial support and sponsorship

This study was funded internally by the Department of Acute Pain Services and Senior Care Services, St. Luke's University Health Network.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

The authors certify that this work is novel clinical research and complies with the rules and regulations of their Institutinoal Review Board and pertinent EQUATOR Network guidelines.The authors also declare that the study was found to be exempt by their Institutional Review Board.



 
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