Evaluation of a Burn Pain and Sedation Clinical Practice Guideline: A Before and After Study The Before Cohort

Purpose: Burn injury is considered the most painful trauma a person can sustain. Management of pain associated with burn injury is complex, and inadequate treatment of burn pain remains a major clinical problem. At Maine Medical Center (MMC), there are concerns that patients’ pain may be undertreated and sedatives may be overutilized, resulting in a decrease in adequate participation in therapy sessions. Physical and occupational therapy is important for recovery in burn-injured patients, as stretching, mobility, and positioning prevent contracture. Early interventions with therapy can prevent decreases in range of motion and strength in these patients. A clinical practice guideline (CPG) was recently implemented to assist with managing pain and sedation in this patient population. This project was initiated to ensure patients with burn injuries are experiencing adequate pain control and are able to participate in therapy sessions with a standardized approach to their pain and sedation management. Methods: An evidence-based CPG for pain, anxiety, and post-burn pruritus management in patients with burn injuries was developed by a critical care pharmacist and a burn nurse practitioner. A multidisciplinary focus group reviewed the CPG prior to implementation. The CPG was implemented in November 2019. This study is a single-center, before-and-after quality improvement project of patients admitted to MMC with burn injury. Patients will be included if they were at least 18 years of age and had a total body surface area burn of greater than or equal to 10 percent. Patients will be excluded if they had concomitant traumatic injuries. Phase 1 (prior to CPG implementation) data will be collected between January 1st 2018 – December 31st 2018 and phase 2 (post implementation) data will be collected between January 1st 2020 – December 31st 2020. Patient charts will be manually reviewed prior to and following implementation of the CPG for specific outcomes. These outcomes include: percent of effective therapy sessions, defined as adequate range of motion and mobility exercises, utilization of a multimodal pain strategy, opioid requirements for background/breakthrough and procedural pain management, pain scores, sedative usage, and degree of sedation. A survey was administered to providers, nurses, and therapists before implementation of the CPG to assess perceptions of pain and sedation management in patients with burn injury. A comparable survey will be administered 3 to 6 months following implementation of the CPG to see if their perception of pain management has changed. Results: The pre-survey was sent to 135 staff members with a total of 61 respondents (45 percent response rate). 100 percent of respondents believed a multi-modal pain management strategy would be beneficial and should be utilized in patients with burn injuries. Roughly 40% of respondents believed their patient did not participate in therapy sessions due to too much pain and 16% believed it was due to oversedation. It was also found that most respondents would like to change the way pain is managed by using combinations of non-opioid and opioid medications and having a consistent practice. Further outcome results are pending, the before cohort outcome results will be available at the time of conference