Chronic Pain Management during the Covid-19 Pandemic: A Scoping Review

BackgroundThe COVID-19 pandemic has led caregivers to modify patient healthcare, with a high impact on patients with chronic pain.AimsTo map recommendations for the management of chronic pain patients during the COVID-19 pandemic and propose a workflow for the management of these patients.DesignThis was a scoping review.MethodsThe databases searched were PubMed, Embase, CINAHL, Scopus, Cochrane Library, and LILACS. The studies were examined by two independent reviewers. The disagreements between reviewers were resolved through discussion or with a third reviewer.ResultsWe presented the results in the form of a table, a workflow, and a narrative summary. The search resulted in 13 studies selected for full reading, including one consensus, five guidance documents, two expert panels, one joint statement, two educational flyers, and two free comments. We considered new technologies, including telemedicine. Each pain service needs to establish a screening model, classifying patients according to corresponding severity. Particular attention should be given to patients who use opioids and are at risk of misusing them. Nonpharmacological approaches and pain education should be maintained, considering the use of telehealth.ConclusionsRecommendations for the management of chronic pain during COVID-19 include adjustments to the patient care model. The workflow proposes the use of telemedicine, screening for painful intensity, and the use of color-signaled intervention packages according to severity (green, yellow, and red).     

Treating CLL with Bruton Tyrosine Kinase Inhibitors: The Role of the Outpatient Oncology Nurse

ObjectivesTo summarize the role of Bruton tyrosine kinase (BTK) inhibitors in the management of chronic lymphocytic leukemia with a focus on the nursing role in relation to patients with chronic lymphocytic leukemia being treated with BTK inhibitors.Data SourcesThese include published articles (PubMed) and national and international guideline documents.ConclusionBTK inhibitors have revolutionized the therapy of chronic lymphocytic leukemia and have become the most frequently used therapy today. Despite the many advantages of BTK inhibitors, adverse events remain a leading cause of treatment discontinuation, particularly for the first-in-class BTK inhibitor. Second-generation BTK inhibitors appear to have a better tolerability profile but still require adverse event management given their prolonged duration of therapy. Awareness and management of side effects by the oncology care team is essential for ensuring both compliance and safety with ongoing treatment.Implications for Nursing PracticeChronic lymphocytic leukemia is a chronic illness with a long-life expectancy. For the patients who require therapy, BTK inhibitor therapy is a frequently applied treatment with impressive efficacy. BTK inhibitors are continued indefinitely until disease progression or significant toxicity; therefore, the overall principles of careful assessment for side effects, diligent management for these, and individualized patient support provided by oncology nurses is vital in this patient population.     

Cross-Sectional Survey to Assess the Status of Lipid Management in High-Risk Patients With Dyslipidemia: Clinical Impact of Combination Therapy With Ezetimibe

BackgroundPrevious retrospective surveys have shown that lipid management goals are well achieved in patients with dyslipidemia at relatively low risk for atherosclerotic diseases. However, more than half of patients in high-risk groups have not achieved the management goals. Since these surveys, newer medications, including rosuvastatin and ezetimibe, have emerged in clinical practice that may influence lipid management.ObjectiveTo assess the current status of lipid management in high-risk patients, we conducted a cross-sectional study between January and March 2010.MethodsEligible patients were those with dyslipidemia who were classified into the primary prevention high-risk or secondary prevention groups according to the Japan Atherosclerosis Society guideline for diagnosis and prevention of atherosclerotic cardiovascular diseases. Patient data were collected from 300 randomly selected physicians at hospitals and clinics across Japan if patients had been receiving the same statin with or without other lipid-lowering agents for ≥3 months. The main outcome was the percentage of patients who achieved the serum LDL-C goal according to the guideline.ResultsData were collected from 1720 patients. The LDL-C goal was achieved in 56.5% of patients (447 of 791) in the primary prevention high-risk group and in 24.5% (103 of 420) in the secondary prevention group by statin monotherapy. For patients who had not reached the LDL-C goal with statin therapy alone, 53.8% (113 of 210) in the primary prevention high-risk group and 63.8% (111 of 174) in the secondary prevention group achieved their lipid management goal with the addition of ezetimibe. Ezetimibe significantly lowered mean serum LDL-C levels by 17.9% to 34.6% when added to various statins (P < 0.001).ConclusionsAlthough strong statins are available, lipid management in high-risk patients remains unsatisfactory. More aggressive treatment is needed for these patients.     

A Screening Tool for Patients With Lumbar Instability: A Content Validity and Rater Reliability of Thai Version

ObjectiveLumbar instability is a condition that has been extensively reported in its prevalence and its effect on patients. To date, however, a clinical screening tool for this condition has not been developed for use in Thailand. The objectives of this study were to translate and test the content validity and rater reliability of a screening tool for evaluating Thai patients with lumbar instability.MethodsThe investigators selected the lumbar instability questionnaire from an original English version. Elements of the tool comprised the dominant subjective findings reported by this clinical population. The screening tool was translated into the Thai language following a process of cross-cultural adaptation. The index of item-objective congruence (IOC) was checked for content validity by 5 independent experts. Seventy-five Thai patients with chronic nonspecific low back pain were asked to report their symptoms. The interview procedure using the tool was conducted by expert and novice physical therapists, which informed the intraclass correlation coefficient (ICC) for inter- and intrarater reliability.ResultsThe IOC was 0.95. The interrater ICC between expert and novice physical therapists was 0.92 (95% CI = 0.88-0.95). The intrarater ICC of novice physical therapist was 0.91 (95% CI = 0.86-0.94).ConclusionThe Thai version of the screening tool for patients with lumbar instability achieved excellent content validity and interrater and intrarater reliability. This screening tool is recommended for use with Thai patients with low back pain to identify the subpopulation with lumbar instability.     

A multimorbidity nurse practitioner-led clinic: Evaluation of health outcomes

BackgroundHealthcare services for people living with multiple chronic diseases have traditionally been organised around each condition, an approach which is neither resource-efficient nor convenient or effective for patients. The integrated nurse practitioner service reported here was developed to optimise patient experience and outcomes within a chronic disease self-management framework.AimTo evaluate patient outcomes following attendance at an integrated chronic disease nurse practitioner clinic for multimorbidity.MethodsA prospective service evaluation of adults with any combination of chronic kidney disease, diabetes and/or heart failure between June 2014 and December 2017. Demographic and clinical outcomes at entry and after 12 months of clinic attendance were collected from health records of all patients (n = 162); a subgroup also completed health-related quality of life and self-efficacy measures at entry and 12 months follow-up (n = 106).FindingsPatients attending the clinic had complex needs and poor health-related quality of life. Despite the complexity of their health problems, as a cohort blood pressure was well-controlled and self-efficacy for chronic disease management was relatively high. Over the first 12 months of integrated nurse practitioner care, there were large improvements in physical aspects of health-related quality of life and many patients achieved reductions in body mass index. Use of hospital inpatient and emergency services also decreased.DiscussionNurse practitioner-led services have the potential to reduce treatment burden and deliver integrated chronic disease management.ConclusionsThe multimorbidity clinic has improved health outcomes in this patient cohort and offers a model for enhanced primary care.     

Heart rate variability biofeedback in chronic disease management: A systematic review

BackgroundHeart rate variability biofeedback (HRVB) is a non-pharmacological intervention used in the management of chronic diseases.MethodA systematic search was performed according to eligibility criteria including adult chronic patients, HRVB as main treatment with or without control conditions, and psychophysiological outcomes as dependent variables.ResultsIn total, 29 articles were included. Reported results showed the feasibility of HRVB in chronic patients without adverse effects. Significant positive effects were found in various patient profiles on hypertension and cardiovascular prognosis, inflammatory state, asthma disorders, depression and anxiety, sleep disturbances, cognitive performance and pain, which could be associated with improved quality of life. Improvements in clinical outcomes co-occurred with improvements in heart rate variability, suggesting possible regulatory effect of HRVB on autonomic function.ConclusionsHRVB could be effective in managing patients with chronic diseases. Further investigations are required to confirm these results and recommend the most effective method.     

Developing team based acute care scenarios: A rural hospital experience

BackgroundHealth professionals work in teams in a variety of health care settings especially in medical emergency teams at times of crisis. However, Registered Nurses (RNs) rarely have the chance to partake in educational programs designed for teams of nurses to practice working together in life-threatening situations. Further RN’s employed in rural setting have less opportunities for professional development than their city based counterparts. Simulated scenarios with a patient actor in a rural hospital have been utilised in this study to provide nurses with the opportunity to work as a team in the early recognition and management of patients with acute medical conditions.AimThis discussion paper focuses on one aspect of a larger research project with the aim of describing the development of team based scenarios for a rural hospital setting, focusing on the detection and management of a deteriorating patient.MethodsThree team based scenarios, the related assessments and feedback techniques are all described.ConclusionTeam based simulation provides a unique opportunity to assist registered nurses in rural settings in re-skilling or maintaining their emergency management skills.     

Predictors of individually perceived levels of team creativity for teams of nursing students in Taiwan: A cross-sectional study

BackgroundThe complexity of healthcare and concurrent advances in technology have promoted Interprofessional Education (IPE) in healthcare schools to prepare students to collaborate on interdisciplinary teams. Since 2016, healthcare curricula in Taiwan have incorporated IPE-based capstone courses to enhance creativity. To better understand the predictors of team creativity could help educators improve IPE and outcomes for nursing students and patients.PurposeTo determine whether nursing students' demographic characteristics, individual creativity, and perceived team interaction behaviors, team swift trust, team conflict, and team task interdependence may predict high perceived team creativity in IPE settings.MethodsA cross-sectional study design included nursing students (N = 99) at a science and technology university in Taiwan. Data from self-report questionnaires included variables for demographic characteristics, individual creativity, and perceived team characteristics. A hierarchical multiple regression analysis revealed predictors of high perceived team creativity.ResultsNursing students who perceived high team creativity also perceived higher interaction behaviors and lower process conflict than those who perceived less creativity. Spontaneous communication and team task conflict predicted high perceived team creativity.ConclusionsNursing educators could increase team creativity in IPE by encouraging spontaneous communication and constructive task-oriented conflict management. This may benefit patient outcomes in the future.     

Hot sand baths (psammotherapy): A systematic review

IntroductionPsammotherapy is a traditional practice in which hot sand baths are employed for therapeutic purposes. This systematic review aims to investigate the potential efficacy of psammotherapy in the treatment of any disease.MethodsMedline via PubMed, Embase, Web of Science, Cochrane Library, and Google Scholar were searched for articles describing studies on the efficacy of psammotherapy in patients with different health conditions. Articles were screened by the two author independently and, in case of disagreements, items were discussed until consensus was reached. All relevant clinical outcomes (symptom and pain relief, modifications in any functional and laboratory parameter, changes in drug consumption, variations of quality of life) were extracted from included studies.ResultsAfter article screening and selection, three studies were included in the review. One study involved patients with chronic obstructive pulmonary disease, while in the other two studies patients with rheumatoid arthritis were recruited. Included trials indicate that psammotherapy might be useful for the management of studied diseases.DiscussionBased on available data, no conclusions can be driven on the clinical efficacy of psammotherapy. However, very limited evidence suggests that hot sand baths might be useful in improving symptoms and functionality of patients with some rheumatic and respiratory chronic illnesses. Further studies are encouraged to better assess the clinical efficacy of hot sand baths.     

Can You Catch It? Lessons Learned and Modification of ED Triage Symptom- and Travel-Screening Strategy

IntroductionEfficient identification and isolation of patients with communicable diseases limits exposure to health care workers, other patients, and visitors. In August 2014, our team developed and implemented an algorithm to triage suspected cases of Ebola virus disease in a midwestern United States emergency department and outpatient clinics based on patient travel history and symptoms. Here, we present the lessons learned and modifications to update the tool.MethodsTwo strategies were developed and utilized to properly identify, isolate, and inform on patients with suspected highly hazardous communicable diseases: 1) a robust electronic symptom and travel screen with decision support tools in the electronic medical record, and 2) the availability of workflow protocols for Ebola virus disease, Middle East Respiratory Syndrome (MERS), and coronavirus 2019 (COVID-19) once a person under investigation is identified. After action reports provided opportunities to modify the algorithm and improve the identification and isolation processes.ResultsSince our screening and travel electronic medical record inception 5 years ago, modifications changed iteratively to further enhance the screening process. Since 2018, staff have identified 5 patients at risk for MERS; in all cases, identification occurred during the check-in process. Exposure investigations in the emergency department decreased significantly after algorithm implementation in January 2019, from 30 in 2018 to 0 in 2019.DiscussionAlthough highly hazardous communicable diseases like Ebola virus disease and MERS are of concern due to their mortality rates and limited treatment options, these same concepts may be applied to the early identification and isolation of patients suspected of having more common communicable diseases like measles and influenza, emphasizing the importance of protocol-based screening in the healthcare environment.     

Pain assessment and management in the newborn: A systematized review

BACKGROUNDNeonatal pain has been underdiagnosed due to several false beliefs.AIMTo determine the status of neonatal pain in newborns who are admitted to intensive care units.METHODSDifferent databases were searched. Literature reviews and research reports conducted in newborns that were written in English, Spanish, or Portuguese, published between 2010 and 2020, and having free access to the full text were selected. A total of 135 articles were found, and 18 articles were finally reviewed.RESULTSNewborns are exposed to numerous painful procedures. In order to assess their pain levels, several scales have been used, although they are sometimes not correctly interpreted. In terms of pain management, the nursing team plays a very important role based mainly on both pharmacological and non-pharmacological approaches. CONCLUSIONNursing staff members must be well trained in order to identify pain and to interpret the scales correctly. Besides, they have an important role in performing non-pharmacological procedures for pain management.     

Quality improvement in cancer symptom assessment and control: the Provincial Palliative Care Integration Project (PPCIP)

ContextThe Provincial Palliative Care Integration Project (PPCIP) was implemented in Ontario, Canada, to enhance the quality of palliative care delivery. The PPCIP promoted collaboration and integration across service sectors to improve screening and assessment, palliative care processes, as well as clinician practice and outcomes for cancer patients.ObjectivesThe project involved 1) implementation of the Edmonton Symptom Assessment System (ESAS) for symptom screening, 2) use of “rapid-cycle change” quality improvement processes to improve screening and symptom management, and 3) improvements in integration and access to palliative care services.MethodsSymptom scores were collected and made accessible to the care team through a web-based tool and kiosk technology, which helped patients enter their ESAS scores at each visit to the regional cancer center or at home with their nurse. Symptom response data were gathered through clinical chart audits.ResultsWithin one year of implementation, regional cancer centers saw improvements in symptom screening (54% of lung cancer patients), symptom control (69% of patients with pain scores and 31% of patients with dyspnea scores seven or more were reduced to six or less within 72 hours), and functional assessment (23% of all patients and 64% of palliative care clinic patients). ESAS screening rates reached 29%, and functional assessment reached 26% of targeted home care patients.ConclusionThe PPCIP demonstrated that significant strides in symptom screening and response can be achieved within a year using rapid-cycle change and collaborative approaches. It showed that both short- and long-term improvement require ongoing facilitation to embed the changes in system design and change the culture of clinical practice.     

老年慢性病患者连续护理小组的设立与效果

目的探讨老年慢性病患者连续护理小组的设立及效果。方法对自愿报名的163名护士进行评估考核,根据考核结果选择40名成绩优秀者组成连续护理小组,并对小组成员进行培训,对需要连续护理的老年慢性病患者实施连续护理。结果小组成员培训后考核成绩显著提高;连续护理实施后患者满意度提高(P0.01)。结论设立老年慢性病患者连续护理小组能提高护士业务水平及操作技能;保障出院患者能得到连续护理,提高其满意度。     

A Healthcare Improvement Initiative to Increase Multidisciplinary Pain Management Referrals for Youth with Sickle Cell Disease

BackgroundChronic pain is a complex integration of biological, psychological, and social variables. Multidisciplinary pain management experts design interventions that treat the multidimensional experience. Children and adolescents with sickle cell disease (SCD) are at risk for chronic pain. Increased risk is associated with multiple characteristics including sickle cell genotype, age, gender, frequency of hospitalization, duration of hospitalization, and certain comorbid diagnoses. Referral to pain management professionals for this population is often delayed.AimsTo increase multidisciplinary pain management referrals for youth with SCD identified to be at risk for chronic pain.DesignImplementation research.SettingOne pediatric, academic medical facility serving as a regional sickle cell treatment center in the Midwest.ParticipantsChildren greater than 2 years of age and less than 21 years of age with laboratory confirmed SCD.MethodsImplementation of an evidence-based screening tool using the consolidated framework for implementation research (CFIR) to guide project planning, design, and evaluation. The CFIR model was paired with the Plan-Do-Study-Act (PDSA) quality improvement methodology to operationalize workflow and sustain project aims.Results and ConclusionsEighty-four percent of all eligible patients were screened during their routine sickle cell appointments resulting in a 110% increase in multidisciplinary pain management referrals. Future interventions and PDSA cycles are targeted at improving attendance at scheduled appointments, reducing hospitalizations, decreasing 30-day readmissions, and shortening length of stay.     

Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs’ experiences

Abstract

Objective: Explore general practitioners’ (GPs’) views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases.

Design: Qualitative content analysis of five focus-group discussions.

Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden.

Subjects: 29 GPs.

Main outcome measures: GPs’ views and experiences of care managers for patients with depression.

Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases.

Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members’ roles must be clear.

• KEY POINTS

• A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs’ experiences of this kind of collaborative care is limited.

• GPs find that care managers provide support for patients and security and relief for GPs.

• GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager.

• GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

     

Diet in Benign Colonic Disorders: A Narrative Review

PurposeDiet plays an important role in common benign colorectal diseases. This article reviews the evidence for diet and supplemental fiber in patients with chronic constipation, irritable bowel syndrome, inflammatory bowel disease, colonic diverticulitis, and fecal incontinence.MethodsWe performed a narrative review of the evidence for diet and supplemental fiber in patients with 5 common benign colonic diseases and summarized guideline recommendations for each condition. We generated tables of practical dietary advice by disease.FindingsDiet advice must be individualized and depends on underlying conditions, disease severity, symptom burden, and nutrition status. Guidance from a registered dietitian is highly recommended when making any dietary changes. Data from trials suggest that soluble fiber is effective for patients with chronic constipation, irritable bowel syndrome, and fecal incontinence. A diet low in select fermentable, oligo-, di-, and monosaccharides, and polyols may benefit patients with irritable bowel syndrome. Patients with inflammatory bowel disease, especially those with active disease, are at risk for malnutrition. Dietary restrictions may further increase that risk. There is limited evidence to recommend increasing or avoiding select food groups in patients with inflammatory bowel disease. Patients who have recovered from diverticulitis should adopt a prudent dietary pattern high in fruits, vegetables, whole grains, legumes, poultry, and fish.ImplicationsClinicians should counsel patients on the contribution of diet to their colorectal condition and the benefits and harms of dietary modification. Dietary advice should be practical and accompanied by realistic expectations for benefit.     

Examining the hurdles in defining the practice of Nurse Navigators

BackgroundNurse navigators are an emerging workforce providing care to people with multiple chronic conditions. The role of the navigators is to identify patients requiring support in negotiating their health care.PurposeA critical discourse analysis was used to examine qualitative data collected from nurse navigators and consenting navigated patients to identify key indicators of how nurse navigators do their work and where the success of their work is most evident.DiscussionNurse navigators help patients who have lost trust in the health system to re-engage with their interdisciplinary health care team. This re-engagement is the final step in a journey of addressing unmet needs, essential to hospital avoidance.ConclusionNurse navigators provide a continuum of authentic and holistic care. To acknowledge the true value of nurse navigators, their performance indicators need to embrace the value-added care they provide.