Date of Award

Spring 5-25-2019

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Karen Macauley, PhD, DNP, MSN

Abstract

Purpose/Aims: This project implemented an algorithmic approach to assess pain, functionality, and psychosocial states in newly diagnosed cancer patients. This was accomplished through utilization of a validated pain assessment tool. The tool’s purpose was to identify high-risk patients for Emergency Department (ED) visits or unanticipated hospital admissions (UHA), within a second-year fellow Hematology/Oncology clinic.

Primary aims included: (a) aggregating demographic data to determine the profile of a high-risk patient seen within this clinic, (b) determining those referred to and who followed up with symptom specialists or the ED, and (c) identifying barriers for the next iteration of the project.

Rationale/Background: According to the National Cancer Institute approximately 1,735,350 Americans will be diagnosed with cancer in 2018. It is estimated that 30-50% of those patients receiving treatment will experience pain caused by malignancy or even the treatment itself. Regrettably, 70-90% of those with metastatic disease will encounter severe discomfort. Uncontrolled pain is distressing and may lead to poor functionality and decreased emotional well-being, unplanned ED visits, and UHA.

Assessing pain alone does not acknowledge the interconnectedness of psychosocial, spiritual and physical duress. To discount these relationships contributes to insufficient care that leads to unnecessary suffering, poor quality of life, and inferior health outcomes. A multicenter survey found 76% of oncologists specified poor pain assessment as the most significant impediment to appropriate pain management.

Therefore, a thorough pain evaluation must be an essential component of the oncologic treatment plan to determine the severity and extent of its physical and emotional impact.

Best Practice: During a three-month data collection period, a weekly chart review was completed to identify eligible, high-risk patients for consultation. The pain assessment was administered after the patient had been seen by the oncologist. If a need for symptom management, mental health services, social work, or nurse navigation was identified, referrals were provided at that visit.

At the conclusion of the collection period, data on all eligible patients was aggregated and analyzed. Additionally, a post-implementation survey was conducted amongst the oncologists to identify any barriers to the process.

Outcomes Achieved: Out of the 121 patients seen, 14 were eligible to participate. Of those, 4 were male and 10 were female. The median age was 70 years old with a range between 56-90 years old. The majority of the patients were diagnosed with Stage IV breast or gynecological malignancies. Of the 14 eligible patients, 5 received the Comprehensive Pain assessment.

Three assessed patients presented to the ED and were hospitalized. Two of the nine patients not seen or assessed were admitted to the ED and hospitalized. The most prominent causes for ED admission were shortness of breath and pain.

Conclusions: Eighty-six percent of patients were correctly identified as being high- risk for ED or hospital admission. The average time to perform the comprehensive pain assessment was approximately 23 minutes. Four out of the five consulted patients were not familiar with the term or functions of palliative care.

To improve upon this early comprehensive pain management tool implementation, future iterations should include: (a) implementing this project within a solid tumor clinic, with particular consideration to breast and gynecological malignancies; (b) providing more information on eligibility criteria to providers; (c) determining a designated space for consultation; (d) performing the consult within one to three visits of diagnosis; (e) administering a pre- and post-implementation survey for patients and providers; and, (f) following patients longitudinally for 6 months or greater.

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