Year of Publication

2021

Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Sheila Melander

Clinical Mentor

Dr. Jacob Higgins

Committee Member

Dr. Candice Falls

Abstract

Introduction: Traumatic fractures are increasing in incidence across the country, particularly in the aging population. Geriatric patients who are admitted to the acute care setting for traumatic fractures are a unique population that require acute pain management, while also managing other comorbidities. While there are several guidelines on pain management for patients who are admitted to the acute care setting, there are no specific guidelines on the best practices to manage acute pain in the geriatric traumatic fracture population. Evidence supports a multimodal pain management strategy using pharmacologic and non-pharmacologic means as the best way to care for this population.

Purpose: The purpose of this practice improvement project research study is to develop an educational intervention focused on multimodal pain management of the geriatric patient with traumatic hip or rib fractures and to determine the impact for the advanced practice provider (APP).

Methods: This research focused on two key areas: the APP education/survey data, as well as the patient chart review data. Assessment of APP knowledge and attitudes was obtained through a pre- and post-intervention survey, and APP practices were assessed through a retrospective and prospective chart review of patients who met the inclusion/exclusion criteria.

Results:Questions regarding overall APP knowledge were found to be significant (p

Questions regarding attitudes of the providers in terms of geriatric patients tolerating pain, completing a comprehensive geriatric assessment with admission, and awareness of the trauma blog were not significant. Survey questions specifically regarding attitudes demonstrated that 71% of APPs were aware that epidural nerve blockades were considered the gold standard treatment for pain management in the geriatric traumatic pain management after the intervention was completed. 80% of APPs reported that a standardized order set would be beneficial for pain management in geriatric traumatic fracture population and 90% of APPs felt they consult pain management when necessary.

Survey questions regarding current practices uncovered that 75% of APPs were aware of the trauma blog protocol, but only 30% of APPs reported using the trauma blog protocol when admitting geriatric traumatic fracture patients. 57% of APPs reported that they consult BEERs criteria most or all of the time when admitting geriatric trauma patients. Questions regarding attitudes of the providers in terms of geriatric patients tolerating pain, completing a comprehensive geriatric assessment with admission, and awareness of the trauma blog were not significant.

Data analysis in the patient chart review demonstrated no significant difference between the pre- and post-intervention chart review groups regarding length of stay, ICU days, total number of narcotics prescribed, discharge disposition, nerve block placement, rapid response calls, intubation/reintubation, ICU return rates, falls, pneumonia, or delirium rates (Table 7). There was a significant difference in pressure injury rates, with rates increasing from 1.6% to 8.7% in the pre- and post-intervention groups, respectively (p=.026). 100% of patients received consults with PT/OT within 24-48 hours of admitting a patient in both the pre- and post-intervention patient groups.

Conclusion: In conclusion, an extensive literature review supports a multimodal pain management protocol for the geriatric traumatic fracture population. While knowledge was improved through the educational intervention with the APPs, there was still a lack of improvement in the day-to-day attitudes and practice of the APP. Future research could be done alongside the APPs working for the service line to develop a standardized order set for all patients admitted to the hospital who would qualify for this pain management approach. The order set could also be developed through interprofessional collaboration between the APP, the pain management team, and the anesthesiologists to improve nerve blockade usage in this population. Using these strategies could improve overall patient outcomes in this population, as well as reduce overall hospital costs for the institution.

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