An evaluation of a program to manage acute postoperative pain in the frail older adult following hip fracture surgery

The purpose of this study was to evaluate selected outcomes of the Frail Elder Pain Management Program (FEPMP) related to postoperative pain management following hip fracture repair at a community hospital. The FEPMP was based on standards of geriatric and pain management practice and consisted of education sessions for nurses and surgeons, pre-printed analgesic order forms, a pain management flow sheet, written resources, and clinical support. Application of the Logic Model as the conceptual framework to the FEPMP demonstrated the conceptual integrity of the program. The hypotheses for the study focussed on measuring changes that occurred in: 1) surgeon's analgesic ordering practices, 2) nursing assessment related to pain, 3) nursing pain management practices. Research questions were related to 1) behaviours related to pain and delirium and overall pain control 2) the adverse effects of analgesia and 3) the use of psychoactive medications to control behaviours that may be related to pain. The charts of 147 patients age 75 and older who had hip fracture repairs were randomly selected and audited from two baseline periods and one period two years after the program was implemented. There were 47 charts in baseline one, (1992-93) 50 charts in baseline two (1994- 95), and 50 in the post-program period (1997-98). There were 124 women and 23 men in the sample with an average age of 83 years. Sixty to 70 percent of the patients had a cognitive impairment and most had at least two chronic conditions. Patients in all three time periods were similar with respect to age, gender, cognitive status and number of pre-existing diseases. The post-program group patients were more likely to have pre-existing pain and a spinal anaesthetic postoperatively. Pain management was more consistent with the standards of practice and patient outcomes improved post-program compared to the baseline periods. The surgeons' prescription practices improved significantly as did the overall pain management practices of nurses. Pain assessment practice showed a modest improvement but this was not statistically significant. Behaviours indicative of delirium and pain were less common in the post-program group. The frequency of restlessness was significantly lower. Agitation, confusion and resistance to care were lower as well although these changes were not statistically significant. Despite more frequent analgesic dosing in the post program group, there was no increase in adverse effects of analgesia. Patient assessments for the first 48 hours postoperatively were reviewed and patients' pain control was described as either good, adequate, poor or unable to be determined. Patients in the post program group were significantly more likely to have good to adequate pain control than the baseline periods where the level of pain control was usually either poor or unable to be determined. The findings of the study were discussed in relation to the literature and methodological concerns inherent in the design were addressed. Implications for nursing practice, administration, and education were described and recommendations for future research were identified.Applied Science, Faculty ofNursing, School ofGraduat