Factors influencing hospital implementation of acute pain management practice guidelines⁶

Abstract

Study Objective: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings.

Design: Two questionnaire surveys.

Setting: Healthcare Association of New York State, Albany, NY.

Measurement: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital’s chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs’ survey data with the clinical directors’ report of guideline usage.

Main Results: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements.

Conclusions: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.

Introduction

Pain is described as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”1 Inadequate treatment of postoperative and other acute pain is well documented in the medical literature.2, 3, 4, 5 In response, several national entities, such as the federal Agency for Healthcare Research and Quality (AHRQ; formerly Agency for Health Care Policy and Research, AHCPR), the American Pain Society (APS), and the American Society of Anesthesiologists (ASA), have developed pain management practice guidelines to facilitate better assessment and treatment of pain.6, 7, 8 Although implementation of these practice guidelines was found to have a favorable impact on improving patient outcomes and satisfaction,9, 10, 11, 12 the guidelines have not been adopted extensively at the local level.

The importance of addressing pain management for improving quality of care is well reflected by the current initiative of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which will use guideline-based measures of pain management in its survey process in the year 2001. This fact presents strong incentives for hospitals and other health care organizations to adopt pain management practice guidelines. Inevitably, there will be increasing interest in what influences the implementation process and how to ensure the successful adoption of guidelines.

A vast amount of research has been conducted to examine factors that affect the implementation of clinical practice guidelines.13 Variables that have been identified as important to guideline implementation include: 1) attributes of guidelines14; 2) physician characteristics, including attitudes about guidelines15, 16, 17; specialty training18; and gender19; 3) practice setting15, 20; 4) patient factors21; and 5) incentives related to financial, legal, and regulatory issues. Nevertheless, to date, few empirical studies have addressed barriers to the adoption of pain management practice guidelines. Most guidelines give little attention to the feasibility of implementing the recommendations across a wide variety of health care settings. In reviewing the AHRQ/AHCPR acute pain management guideline, Carr and colleagues suggested that the following local resource shortfalls might limit implementation22: 1) lack of staff trained and knowledgeable in pain management, 2) lack of specially trained nurses or psychologists to deliver nondrug interventions, 3) lack of formal quality assurance or other institutional programs to monitor pain management, 4) absence of equipment necessary to deliver some of the interventions, 5) lack of specialists with the requisite expertise to insert and monitor epidural catheters, and 6) lack of resources to provide the education to clinicians to implement the guideline.

Prior studies on clinical practice guidelines tend to focus on physicians’ perspectives on guideline implementation, while little is known about health executives’ perspectives on barriers to guideline adoption. Good understanding and support from hospital administration is imperative to the successful implementation of acute pain management practice guidelines. This study seeks to facilitate understanding of select issues related to implementation of a clinical practice guideline on acute pain management. Three questions were addressed through surveys of hospital chief executive officers (CEOs) and clinical directors. First, what are the hospital CEOs’ perceptions of factors influencing pain management guideline implementation? Second, how do current pain management practices, as reported by the clinical directors, compare to what is recommended by the guideline? Third, do hospital CEOs’ perceptions of issues related to guideline implementation predict the adoption of guideline elements as reported by the clinical directors?