Impact of a Clinical Decision Support Tool on Cancer Pain Management in Opioid-Tolerant Inpatients

Abstract

Pain is both common and undertreated in the hematology/oncology population despite national guidelines and a focus from The Joint Commission. Herein, we describe the features of a pain clinical decision support tool (PCDST) embedded into the electronic medical record (EMR) and report its impact on oncology inpatients at risk for uncontrolled pain. The PCDST was developed to identify patients with potentially uncontrolled pain, defined as a pain score ≥4. Clinical pharmacists were encouraged to use the tool to determine whether interventions were needed to better control pain. Pain and safety outcomes between 2 cohorts of opioid-tolerant adult inpatients presenting with severe pain were compared prior to and following the implementation of the PCDST. The primary endpoint, attainment of analgesia at 24 hours from admission, was met in 10 of 30 (33.3%) patients in the preimplementation group and in 14 of 32 (43.8%) of patients in the postimplementation group ( = .78). Secondary endpoints including time to analgesia, mean pain score, frequency of pharmacy intervention, and National Comprehensive Cancer Network (NCCN) guideline-adherent pain regimens were not found to be statistically significantly different between the 2 groups. The number of mean nursing pain assessments in the first 24 hours from admission was found to be significantly higher in the postimplementation group compared with the preimplementation group (12 vs 7.4, < .001). Safety events were rare and not statistically different between groups. Overall, a modest, but statistically nonsignificant, improvement in pain outcomes was associated with patients admitted after the implementation of a pharmacist-managed electronic pain scoring tool.

The Effect of Higher Level Computerized Clinical Decision Support Systems on Oncology Care: A Systematic Review

“…Bertsche et al showed no significant change in pain intensity score (NVAS) on day 5 after admission, after implementation of a CDSS [34]. Similar, Christ et al showed no significant difference in mean pain score at hospital admission and after 28 h [28].…”

“…Six studies targeted multiple specialisms; the others focused on one specialism. CDSSs of included studies focused on risk assessment or therapy options to support informed decisions [26][27][28][29][30][31][32], as well as statistical methods and data mining to generate patient-specific recommendations [33,34]. For most studies (7/9), clinical guidelines formed the knowledge base of the CDSS.…”

“…Six studies reported process outcomes ( Table 2). The issues addressed included: use of CSF to control chemotherapy-induced febrile neutropenia [26,27], physician-prescribing behavior [32], clinical trial rate [32], attainment of analgesia [28], time to analgesia [28], frequency of pharmaceutic intervention and pain assessment [28], costs [33] and workload [31]. Comparators included usual care, based on either MDT decisions or clinical guidelines.…”

“…Five studies assessed adherence to clinical practice guidelines (Table 3) [28][29][30]32,34]. Three studies showed improvement in guideline adherence in breast cancer management [29,30,32], two studies showed conflicting results in guideline adherence in pain management [28,34] and no significant difference in guideline adherence in prostate cancer management was reported [29].…”

“…With use of the Robins-I tool, the risk of bias is rated critical in six [28][29][30][31][32]34] studies and serious in three studies [26,27,33]. An overview of the risk of bias scoring is provided in Figure 2.…”