Jeremy J Bennett, RN, BSN Evidence-Based Practice Fellow GONDA Observation UNIT (GOU) Ronald Reagan UCLA Medical Center

1. Evidence Based Guideline for Use of Audio Pain-Centered Guided Imagery as an Adjunct for the Management of Chronic Pain in GONDA Observation Unit (GOU) Jeremy J Bennett, RN, BSN Evidence-Based Practice Fellow GONDA Observation UNIT (GOU) Ronald Reagan UCLA Medical Center

2. Clinical Issue The practice issue we addressed was the control of chronic pain in patients staying in GONDA Observation Unit adjunctively with the current use of their established pain regimen Many of our patients have a history of chronic pain Many times prescription medication is not enough and we as nurses could use alternative nursing interventions to help better control chronic pain

3. Definition of Terms • Chronic pain – • > 30 days beyond the usual course of an acute disease /injury • Chronic pathological process that causes continuous pain (Persson, et al 2008) • Guided Imagery – • An immersive, hypnotic, self-administered audio intervention • Delivers soothing words and music • Drives attention inward and structures a healing experience that targets specific goals (Naparstek 2011) • Increases patient’s control over their pain (Lewandowski, et al 2005)

4. Current Practice • Prescription medications – current home pain regimen plus in-house prn medications • Comfort measures – heating/cooling packs, elevation, distraction, etc. • Guided imagery not readily available or accessible to staff RNs

5. Significance of Problem Chronic pain is a widespread problem for many patients admitted to GOU The majority of patients admitted to GOU suffer from chronic pain Pain management is complex and may not be enough Patients suffering from chronic pain many times feel that they have no control over their pain

6. Purpose Provide an evidence-based guideline for the use of an audio pain-centered Guided Imagery intervention as an adjunct for the management of chronic pain for patients in GOU Increase Staff RN knowledge of guided imagery intervention Decrease pain for our chronic pain patients

7. Evidence-Based Practice Question In patients admitted to GONDA Observation Unit who suffer from chronic pain does implementing the addition of an evidence-based Guided Imagery (GI) intervention as compared to usual care (current pain management regimen) improve pain management?

8. What Does the Evidence Tell Us • Many GOU patients experience chronic pain diagnoses such as: • Arthritis/Osteoarthritis/Neck and spine pain • Fibromyalgia/Neuropathy • Sickle Cell Disease • Pharmacological therapy alone may not be sufficient to control the pain • Guided imagery is an adjunctive therapy that has been shown to decrease the need for and reliance on pain medications (Hollins et al. 2012) • Patient's perception of pain may be altered and their ability to control their pain may become enhanced (Hart 2008; Ozu 2010; Lewandowski, et al 2005)

9. What Does the Evidence Tell Us About Both the Physical & Psychological Effects of Guided Imagery? • Physical Effects (United States Department of Health & Human Services 2012): • Decreases blood pressure, heart rate, O2 consumption, and levels of stress hormones • Slows breathing • Encourages a sense of well-being • Psychological Effects (Lewandowski, et al 2005; Ozu 2010): • Focuses on interaction between the brain, mind, body, and behavior • Explores the powerful ways emotional, mental, spiritual, social, and behavioral factors can directly affect health • Changing the patient’s pain experience (Ozu 2010): • Their pain is under their control • They have the power themselves to decrease and control their pain • Their perception of pain and daily life begin to change

10. Mayo Clinic – Mayo Clinic Guide to Alternative Medicine 2011 Baur, Brent MD. (2010). Mayo clinic guide to alternative medicine 2011: Top 10 alternative therapies, control your stress and more (Revised and Updated ed.). Time Home Entertainment. “Green Light” – In treating a variety of health problems it provides multiple benefits and poses virtually no risks PET scanning found that the same parts of the brain are activated when people are imagining something as when they’re actually experiencing it!

11. Partial List of Evidence Hollins M, Stonerock G, Kisaalita N, Jones S, Orringer E & Gil K. Detecting the Emergence of Chronic Pain in Sickle Cell Disease. Journal of Pain and Symptom Management. June 2012, 43 (6): 1082-1093. Lewandowski W, Good M, Draucker CB. Changes in the meaning of pain with the use of guided imagery. Pain ManagNurs. 2005 Jun, 6(2): 58-67.   Persson A L, Veenhuizen H, Zachrison L, Gard G.  Relaxation as treatment for chronic musculoskeletal pain: a systematic review of randomised controlled studies. Physical Therapy Reviews 2008; 13(5): 355-365. Hart J. Guided Imagery. Alternative and Complementary Therapies. December 2008, 14(6): 295-299. Özü, Ö. (2010). Guided imagery as a psychotherapeutic mind-body intervention in health psychology: A brief review of efficacy research. Europe’s Journal of Psychology, 6(4), 227-237. Naparstek B. Guided Imagery: A Portable, Self-Administered, Low-Cost, Effective, User Friendly Tool for Posttraumatic Stress. Health Journey’s: PowerPoint slides retrieved from George Mason University College of Health and Human Services. 2011. United States Department of Health and Human Services, National Institutes of Health, & the National Center for Complementary and Alternative Medicine. (2012). Relaxation techniques for health: an introduction (NCCAM Publication No. D461). Maryland: National Center for Complementary and Alternative Medicine. Retrieved from http://nccam.nih.gov/sites/nccam.nih.gov/files/D461.pdf

12. Criteria for Project • Inclusion: • History of chronic musculoskeletal pain, neuropathy/fibromyalgia, and sickle cell disease • Patients whose primary admission diagnosis includes acute pain in addition to the history of chronic pain • Both inpatient and observation patients • Exclusion: • Non-verbal patients • Confused or disoriented patients • Deaf patients • Non-English speaking patients

14. Interventions

15. Interventions Developed and implemented an evidence-based guideline Assessed nurses' baseline knowledge of key aspects of the Evidence-Based Guideline Educated nurses on new practices and guideline Reassessed nurses' knowledge post education session Provided coaching and mentoring at the bedside to facilitate understanding and adherence to new practice Evaluated effect of adjunctive therapy on patient’s pain scores

16. Outcomes

17. Outcomes Measured Two sets of outcomes were measured: • Knowledge Outcomes: RN knowledge survey (pre and post intervention) • Practice Outcomes (post-intervention) • Appropriate documentation of pain scores both pre & immediately post intervention on the Verbal Numeric Rating System • Effect on patient’s pain score immediately post-intervention

18. Results of RN Survey: Knowledge and Self-Reported Practices N = 26

19. Demographic Characteristics of the Sample Pre and Post Survey

20. Demographic Characteristics of the Sample Pre and Post Survey

21. Demographic Characteristics of the Sample Pre and Post Survey

22. Results: Percent Correct Score on Pre and Post Knowledge Survey Among Nurses

23. Educating Nurses

24. Mean Confidence/Attitude Score of Composite Score

25. Results: Nurses’ Perspective on Non-Pharmacological Methods of Pain Control

26. Results: Perception of Treating Chronic Pain

27. Results: Perspective on Use of GI

28. Results: Nurses’ Knowledge and Skill in Using Guided Imagery

29. Results: Other Comments by Nurses

30. Results: Strategies to Consider in Managing Patients Chronic Pain in the GOU Environmental Modification Integrating Alternative Therapies With Medication Regimes Could also be useful for other patients than only those with Chronic Pain (i.e., anxiety, emotional disorders, depression, etc.) Integrating MD and NP knowledge and support of intervention There are many alternatives out there other than prescription medication to control chronic pain

31. Practice Outcomes N= 2

32. Patients Perception of GI Intervention Both utilized GI for 15 minutes Only one had only tried some relaxation techniques in the past The patient who concurrently used prescription meds stated she felt the GI intervention further helped treat her pain and that she was pleased with the therapy and wanted to continue utilizing it in conjunction with her pain meds

33. Barriers/Limitations to Continuing Guided Imagery Eleven nurses were surveyed post intervention • Patients’ willingness and openness to try • Many patients on long term prescriptions may be hesitant • Time – sitting down and talking to the patient • Interruptions to patient/Noises • Short stay observation patients

34. RN Post Intervention Survey 100% would be willing to try for themselves 100% thought it was a valuable tool that should be kept 10 of the 11 felt comfortable talking to their patients 9 of the 11 felt patients with other diagnoses in GOU would benefit

35. Conclusions Many chronic pain patients are admitted to GOU, including almost all of UCLA RR Sickle Cell patients Alternative therapies to use adjunctively with medication are not always readily available in GOU Staff nurses in GOU were educated and trained to utilize a pain-centered GI Intervention In the 2 patients who utilized the intervention, both reported a decrease in pain and increase in relaxation GOU will continue our trial of GI with chronic pain patients

36. Future Plans Continue utilization of guided imagery intervention Work with unit leaders and colleagues to integrate guideline into unit routines through performance improvement processes and include in orientation program and annual skills day Consider use for diseases other than chronic pain alone Disseminate to other units, and throughout the nursing department in a variety of forums Consider dissemination nationally via abstract submission and publication

37. Acknowledgements to Team • GONDA Observation Unit Nursing Staff • GONDA Chronic Pain Patients • Mark Flitcraft RN, MSN, Unit Director • Miriam Gonzalez, RN, MS, EBP Clinical Mentor Key Stakeholders/Change Champions • Sofie • Rosa • Diana • Patricia • Krishna • Amelia • Tina • Geraldine

38. Questions and Comments