Bundling Interventions to Enhance Pain Care Quality (BITE Pain) in Medical Surgical Patients ORIGINAL RESEARCH Ochsner Journal 19:77–95, 2019 © Academic Division of Ochsner Clinic Foundation DOI: 10.31486/toj.18.0164 Bundling Interventions to Enhance Pain Care Quality (BITE Pain) in Medical Surgical Patients Karen L. Rice, DNS, APRN, ACNS-BC,1 Julie Castex, MSN, APRN, ACNS-BC,1 Margaret Redmond, MN, APRN, ACNS-BC,2 Jeffrey Burton, PhD,3 Jia-Wen Guo, PhD, RN,4 Susan L. Beck, PhD, APRN, FAAN4 1Center for Nursing Research, Ochsner Clinic Foundation, New Orleans, LA 2Palliative Medicine, Ochsner Clinic Foundation, New Orleans, LA 3Center for Outcomes and Health Services Research, Ochsner Clinic Foundation, New Orleans, LA 4College of Nursing, University of Utah, Salt Lake City, UT Background: Inadequate pain management and undertreatment remain a serious clinical issue among hospitalized adults, con- tributing to chronic pain syndromes and opioid dependency. Implementation of individual pain care interventions has been insufficient to improve pain care quality. The purpose of this interprofessional, patient-centered project was to implement a 6- component bundle of evidence-based pain management strategies to improve patients’ perception of pain care quality and 24-hour pain experience outcomes. Methods: A quasi-experimental design was used to test the effect of a bundled pain management intervention on 3 medi- cal surgical units. Baseline outcomes using the Pain Care Quality-Interdisciplinary (PainCQ-I©) and Pain Care Quality-Nursing (PainCQ-N©) surveys were measured monthly for 4 months preintervention and 30 months postintervention. Results: A convenience sample of 846 patients was analyzed. The effect of the intervention on pain outcomes could not be tested because unit-based adherence did not meet the goal of 80%. A subsample of 70.2% (594/846) of participants was sufficient to com- plete a 3-group analysis of preintervention and postintervention participants with confirmed intervention adherence. Participants in the postintervention group who received all 6 components (n=65) had significantly higher odds of higher PainCQ© scores than those in the preintervention group (n=141) (PainCQ-I©: odds ratio [OR] 2.61, 95% confidence interval [CI] 1.54-4.42; PainCQ-N©: OR 3.82, 95% CI 2.06-7.09) or those in the postintervention group receiving �5 components (n=388) (PainCQ-I©: OR 2.52, 95% CI 1.57-4.03; PainCQ-N©: OR 3.84, 95% CI 2.17-6.80). Conclusion: Medical surgical patients participating in this study who received the bundled 6-component intervention reported significantly higher levels of perceived pain care quality, suggesting that a bundled approach may be more beneficial than unstan- dardized strategies. Keywords: Acute pain, animal assisted therapy, aromatherapy, implementation science, interprofessional relations, music ther- apy, pain–postoperative, pain management, pain measurement, quality indicators–health care, quality of health care, surveys and questionnaires Address correspondence to Karen L. Rice, DNS, APRN, ACNS-BC, Center for Nursing Research, Ochsner Clinic Foundation, 1514 Jefferson Hwy., New Orleans, LA 70121. Tel: (504) 343-3688. Email: karen.rice53@gmail.com INTRODUCTION Pain in the United States is a public health crisis of epi- demic proportions.1 Approximately 100 million Americans suffer from acute and chronic pain at an annual cost reaching $635 billion, more than the combined healthcare expendi- tures for diabetes, cardiovascular disease, and cancer.2 Pain management is widely accepted as an important compo- nent of high-quality care and a strong contributor to patient satisfaction.3-5 Despite awareness and therapeutic improve- ments, inadequate pain management and undertreatment of pain remain a serious clinical issue among hospitalized patients, contributing to chronic pain syndromes and opi- oid dependency.6,7 Clearly, implementation of individual pain care interventions has been insufficient to improve patients’ perceptions of pain care quality.8-11 Therefore, there is a need to implement an innovative pain management intervention that (1) actively engages the patient as a partner rather than a passive recipient of treatment; (2) applies bundled interven- tions that are complementary and conceptually aligned; and (3) improves patients’ ability to cope with pain by providing some predictability and engaging them in control regarding the plan of care.12,13 LITERATURE REVIEW A review of the published literature cited in Ovid MED- LINE and CINAHL focused on exploring the effectiveness of Volume 19, Number 2, Summer 2019 77 BITE Pain TherapyTM outcomes of pharmacologic and nonpharmacologic nursing interventions in reducing acute and chronic pain in adult hos- pitalized patients. Four systematic reviews and 21 original research studies published from 2003-2014 were critiqued for level of evidence using the Centre for Evidence-Based Medicine guideline14 and provided the basis for the interven- tion in this research study. The literature synthesis is briefly described beginning with the highest level of evidence (systematic reviews). Four systematic reviews supported a benefit in pain outcomes related to patient pain education,15 therapy,16 and non- pharmacologic therapy.17,18 Six randomized controlled tri- als described beneficial pain management outcomes from patient education19 and nonpharmacologic therapy.20-24 Two quasi-experimental studies supported a benefit in pain outcomes related to structured pain rounds25 and nonphar- macologic therapy.26 Thirteen descriptive, comparative, or correlational designs described positive pain care quality outcomes associated with patient pain education,27 pain and coping assessment strategies,28-33 communication of pain management plans,34 pharmacologic therapy,35 and non- pharmacologic therapy.36-39 Although pharmacologic agents have been the mainstay of pain management, synthesis of this body of knowledge suggests that the evidence is insufficient to support a spe- cific nursing intervention that effectively manages pain. Yet case studies that tested individual nonpharmacologic inter- ventions in the 2010 Pain Care Quality Study reported by Potter et al40 reported a potential benefit for hospitalized adults at single sites. Interventions described in the liter- ature review supporting this study were associated with a potential benefit as adjuncts to pharmacologic therapies that included patient education, clinical pathways, teaching patients coping strategies, and various nonpharmacologic therapies (massage, relaxation, guided imagery, pet ther- apy, music therapy, prayer, distraction) in improving patients’ perceptions of pain management. None of these interven- tions was found to be harmful or of less benefit than usual care. However, despite the state of knowledge about various adjunctive strategies to individualize pain management in hospitalized adults with acute and chronic pain syndromes, important substantive and theoretical questions exist. These gaps include that little or no knowledge exists regarding the effect of bundling pain care strategies on patients’ percep- tions of pain care quality. However, structured quality improvement initiatives and observational cohorts using bundled interventions to improve hospital outcomes in ventilator-associated pneu- monia (VAP)41,42 and septic shock43,44 support improvement in these outcomes when bundle adherence with completing all bundle components reaches and exceeds 80% over time. Although quality improvement and observational stud- ies are not strong evidence to support the role of bundle adherence in improving quality outcomes in VAP and septic shock, the literature does support a relationship between bundle adherence and quality outcomes.41-43 Therefore, it seemed plausible to test the same bundling concept using the 80% adherence goal in implementing all 6 pain care strategies as one bundle in an intervention study. This research study addressed the knowledge gap and sought to test an important substantive clinical question: determining the effect of a 6-component bundle of pain care strategies, BITE Pain TherapyTM (Bundling Interventions to Enhance Pain Care Quality), on patients’ perception of pain care quality. The purpose of this nurse-driven, interprofes- sional, patient-centered project was to implement BITE Pain TherapyTM, a standardized bundle of conceptually aligned evidence-based pain care management strategies, to improve patients’ perception of pain care quality by actively engaging the patient as a partner rather than a recipient of treatment. Active engagement of the patient as a healthcare team partner using BITE Pain TherapyTM was facilitated by 6 bundle components that (1) defined and communicated pain care expectations and (2) determined appropriate pain care interventions. This study was particularly important because if the hypothesis that the BITE Pain TherapyTM intervention improves medical surgical patients’ perceptions of pain care quality was supported, nurses could add a bundle of evidence-based, pragmatic, and readily accessible pain care strategies to their armamentarium in the battle against pain in hospitalized patients. RESEARCH QUESTIONS The research questions that guided this scientific inquiry were (1) To what extent does implementation of a unit- based standardized bundle of evidence-based pain care components (BITE Pain TherapyTM) improve medical surgi- cal patients’ perception of pain care quality over time? and (2) Is there a relationship between BITE Pain TherapyTM inter- vention adherence, patients’ perception of pain care quality, and pain experience outcomes? METHODS Design A quasi-experimental interrupted time series design was used to evaluate the effect of the BITE Pain TherapyTM inter- vention on patients’ perceptions of pain care quality and 24- hour pain experience outcomes. Unit-level pain quality data were collected monthly for 4 months before implementa- tion and 30 months after. Unit intervention adherence data were collected weekly and averaged monthly. The study was performed according to good clinical practice principles and was approved by the participating facility’s institutional review board (IRB). Setting The study was conducted on 3 medical surgical units in a 550-bed quaternary acute care academic facility in metropolitan New Orleans, LA, with Magnet Recognition® (American Nurses Credentialing Center, Silver Spring, MD). Patients on each of the 3 adult units are primarily specialty populations: gastrointestinal disorders (38 beds), orthope- dics (42 beds), and transplant (34 beds). However, all 3 units are similar in that >60% of the patients are admitted for major surgical procedures. Sample and Sampling Plan A convenience sample of all patients meeting inclusion criteria on the 3 participating medical surgical units was recruited to participate in the study. The sampling plan involved recruiting patients on a predetermined day of each month during the 4-month preintervention and 30-month postintervention periods. All patients on each unit were screened by study staff for eligibility using the electronic 78 Ochsner Journal Rice, KL Figure 1. BITE Pain Therapy TM (Bundling Interventions to Enhance Pain Care Quality) objectives and components. health record and daily unit census reports. All eligible patients were invited to voluntarily consent to participate if the inclusion criteria were met: �18 years old, on that unit at least 24 hours, complaint of pain in the last 24 hours with an active order for pharmacologic analgesic, and able to speak and read English. Patients were excluded if they had a his- tory of cognitive dysfunction, an acute mental status change, or a medical condition that precluded their ability to partici- pate in a 15-minute interview for collecting data. Intervention The BITE Pain TherapyTM intervention was implemented on November 1, 2014 as a new best practice for the man- agement of acute and chronic pain for all patients hospi- talized on the 3 participating units. BITE Pain TherapyTM, a 6-component bundled intervention, was developed by the investigators based on the synthesis of evidence previously described in the literature review. The 6 bundle components (Figure 1) included (1) patient education regarding pain and pain management (pain brochure and individualized instruc- tion); (2) pain and coping with pain assessments using the 0-10 numeric rating scale with faces; (3) structured pain rounds every hour during the day and every 2 hours at night if the patient was awake; (4) communication of the pain man- agement plan (comfort goal and time next analgesic dose available) written on the patient’s wall-mounted whiteboard; (5) pharmacologic management; and (6) the offer of menu- driven adjunctive nonpharmacologic therapies. Although these bundle components are congruent with the standard of care, the development of a coping with pain assessment instrument (Figure 2) and a menu for patients to select nonpharmacologic therapy options were innova- tive additions to the intervention. Patients were provided a menu, Take the BITE Out of Pain, on admission (Figure 3). The expectation was that all patients with a complaint of pain would be offered the entire 6-component BITE Pain TherapyTM bundled intervention each shift as the new stan- dard of care. Each participating unit was supplied with two supply carts called comfort carts that included nonphar- macologic therapies (ie, essential oils, distraction materials, massagers). Comfort carts were audited, and the supplies were replaced each week or more often if nurses reported a need. All participating unit-based provider stakeholders (nurses, advanced practice nurses, physicians, physician assistants, clinical pharmacists, social workers, physical and occupa- tional therapists, pastoral care providers) received educa- tion regarding the BITE Pain TherapyTM intervention, includ- ing information about knowledge and attitudes about pain management and implementation of the pain care bundle. Nurses’ competencies in completing all bundle components were validated using role modeling and case study vignette simulations. The institution’s Pain Task Force accepted Figure 2. Ability to cope with pain rating scale. Volume 19, Number 2, Summer 2019 79 BITE Pain TherapyTM Figure 3. Nonpharmacologic therapy menu. responsibility for facilitating physician and advanced prac- tice clinician (nurse practitioners, physician assistants) pain management education involving the BITE Pain TherapyTM bundle. Ongoing education was facilitated using online intranet-based educational modules, skills fairs, and unit- based huddles. Measurement and Instruments Pain Care Quality (PainCQ©). Patients’ perception of pain care quality, the primary endpoint, was measured using 2 dif- ferent surveys: Pain Care Quality-Interdisciplinary (PainCQ- I©) and Pain Care Quality-Nursing (PainCQ-N©) surveys.45 These surveys collect information about the patient’s pain care experience in the context of a specific encounter and provider interactions during hospitalization. The surveys focus on a comprehensive assessment of pain manage- ment that impacts the patient, family, and friends, including nonpharmacologic therapies and fear of addiction. Patients’ perception of pain care quality was measured using the PainCQ© surveys monthly during 2 periods: preintervention (4 months) and postintervention (30 months). In addition, demographic information and 5 selected items from the Brief Pain Inventory46 about participants’ pain experience during the previous 24 hours were solicited at the same time the PainCQ© surveys were administered. While demographic items included self-reported type of pain (acute, chronic, or both types), the 5 items eliciting information about patients’ pain experience during the previous 24 hours focused on pain outcomes (average pain level, time in severe pain, frequency of pain medication administration, percent pain relief from medications, ability to cope with pain). Preinter- vention participants completed the same PainCQ© surveys as postintervention participants with one exception. Demo- graphic items in the preintervention survey did not request participants to self-identify the type of pain they were cur- rently experiencing. Following informed consent, trained data collectors used pen and paper surveys to collect information via structured interview. Permission to use and revise the Pain Care Quality surveys was granted by the developer. The original 20-item 80 Ochsner Journal Rice, KL Table 1. Confirmatory Factor Analysis for PainCQ© Survey Data Test Statistic Criteria for Good Model Fit PainCQ-I© (n=846) PainCQ-N© (n=846) Number of items 6 15 Chi-square (df) 21.49 (8) 372.79 (83) P value for chi-square <0.05 0.006 <0.001 Chi-square ratio χ2/df (<3) 2.69 4.48 Comparative fit index �0.95 0.99 0.95 Goodness-of-fit index �0.95 0.99 0.94 Standardized root mean square residual �0.08 0.023 0.050 Root mean square error of approximation �0.08 0.045 0.065 Note: Missing data replaced with subscale mean to facilitate complete dataset for confirmatory factor analysis. df, degrees of freedom; PainCQ-I©, Pain Care Quality-Interdisciplinary; PainCQ-N©, Pain Care Quality-Nursing. survey includes pain care quality items specific to interdis- ciplinary care (6 items) and nursing pain care (14 items).45,47 Altogether, these 20 items specifically measure patients’ per- ception of pain care quality, and they make up the PainCQ- I© and the PainCQ-N© surveys. The 6 items included on the PainCQ-I© survey are categorized under 2 subscales: Part- nership with the Health Care Team (3 items) and Comprehen- sive Interdisciplinary Pain Care (3 items). The 14 items on the PainCQ-N© survey are categorized under 3 subscales: Being Treated Right (7 items), Comprehensive Nursing Pain Care (4 items), and Efficacy of Pain Management (3 items).47 Both the PainCQ-I© and PainCQ-N© surveys use a 6-point Lik- ert rating scale (1=strongly disagree to 6=strongly agree) to elicit information about pain care quality related to interdis- ciplinary care since admission to the hospital (ie, PainCQ- I©) and nursing care during the previous 12-hour shift (ie, PainCQ-N©). Higher scores indicate better pain care quality. Because the BITE Pain intervention included an option of nonpharmacologic therapies thought to improve patients’ ability to cope with pain,17,18,48,49 it was important to assess the patients’ baseline coping ability and the impact of nurs- ing care as confounding variables. Therefore, 2 additional questions were developed in collaboration with the instru- ment developer. One of the items previously mentioned in the 5-item section that assessed the patient’s pain experience during the last 24 hours—Please rate how effectively you are coping with pain on the average during past 24 hours—uses a numeric rating scale with faces (10=coping all the time to 0=never coping). The second question—The nurse did a good job helping me to cope with my pain—was added to the PainCQ-N© Being Treated Right subscale items, increasing this subscale to 8 items. Information from 34 survey items (8 demographic, 5 pain experience, 20 PainCQ©, plus 1 new coping question) were collected from participants. The 20 items making up the original PainCQ-I© and PainCQ-N© surveys47 have psychometric estimates to sup- port reliability and validity in measuring patients’ percep- tions about pain care quality. All 5 subscales have previously reported satisfactory internal consistency reliability and con- struct validity via confirmatory factor analysis (CFA).47 Inter- nal consistency reliability for each subscale of the PainCQ- I© (6 items) and revised PainCQ-N© (15 items) surveys used in this study were satisfactory. Cronbach’s α for the individ- ual subscales was 0.69 (Partnership with the Health Care Team), 0.71 (Comprehensive Interdisciplinary Pain Care), 0.87 (Being Treated Right), 0.71 (Comprehensive Nursing Pain Care), and 0.88 (Efficacy of Pain Management). CFA supported the validity of the construct in this study, and the data fit the model for both the PainCQ-I© and revised PainCQ-N© surveys (Table 1). BITE Pain TherapyTM Intervention Fidelity. Measuring intervention adherence is critical to determining whether per- ceptions of pain care quality are attributable to the interven- tion or to some other confounding variable. The researchers developed an audit tool to measure patients’ perception of nurses’ adherence with each of the 6 bundle compo- nents using a dichotomous (yes/no) response. Patients were selected for auditing based on the same eligibility crite- ria used in conducting the PainCQ© surveys. Using the same audit instrument, 2 strategies were used to assess the impact of the intervention on patients’ perception of pain care quality and pain outcomes. First, unit-based adherence of the intervention was captured weekly but at a different time than pain care quality and pain outcome data collec- tion. Second, individual participant intervention adherence was collected monthly at the same time as pain care quality and pain outcome data collection, providing paired data for some participants in the postintervention group. Unit-Based Intervention Adherence Audits. Unit-based audits were conducted by research assistants each week via patient interview and observation. Consented patients were interviewed regarding their recollection that the bundle options were offered during the prior 24 hours and by obser- vation of written communication of the pain management plan on whiteboards in the hospital room. Bundle adherence audits were scored to determine the percentage of adher- ence for each bundle component and for all 6 bundle compo- nents. This information was communicated back to nurses on each participating unit weekly to foster improved adher- ence with all 6 bundle components over time. In addition, nurses were encouraged to anonymously complete a pocket card weekly to communicate processes that worked well or presented obstacles to bundle adherence (Figure 4). Individual Participant Intervention Adherence Audits. To investigate the effects of the bundle components on improv- ing the perception of pain care quality, defining and capturing participants’ exposure to the intervention were necessary. In June 2015, the protocol was amended and approved by Volume 19, Number 2, Summer 2019 81 BITE Pain TherapyTM Figure 4. Nurses’ pocket card to assess what was working and not working. the IRB. In addition to the monthly intervention adherence audits, this amendment provided a mechanism to capture individual participant intervention adherence data on some of the postintervention group at the same time as pain care quality and pain outcome data were collected. Participant data from the entire preintervention (n=141) period and from individual audits (n=453) from some in the postintervention period were categorized into groups according to their exposure to the intervention. Three groups were defined: Group 1 Preintervention (no bundle), Group 2 Postintervention (offered 0-5 bundle components), and Group 3 Postintervention (offered all 6 bundle components). The team’s rationale was (1) no one in Group 1 was exposed to the bundle; 2 of the components were not available (abil- ity to cope with pain assessment and nonpharmacologic menu); (2) participants in Group 2 who reported receiving 0-5 components were exposed to at least 1 component (phar- macologic analgesia was an inclusion criterion) during their hospitalization even if they were not consciously aware; and (3) the number of participants in Group 3 who reported receiving all 6 bundle components at the time PainCQ© sur- vey data were collected supports intervention adherence. Therefore, the primary analysis of the effect of the bun- dled intervention focused on comparing the pain care quality scores and pain outcomes of 3 participant groups that had paired data to support whether or not exposure to the inter- vention occurred. DATA ANALYSES Exploratory data analysis was conducted to examine the distributions of each study variable, primary and secondary endpoints by means ± standard deviations, and frequen- cies and percentages. Medians and interquartile ranges were reported when continuous data were not normally dis- tributed. All analyses were completed using SAS/STAT soft- ware, v.9.4 of the SAS System for Windows. All tests were performed with significance level α=0.05. Pain experience outcome data were dichotomized into 2 groups of responses for average pain (low=0-4 rating vs high=5-10 rating), time in severe pain (0%-25% vs 26%- 100%), amount of relief from pharmacologic analgesia (0%- 75% vs 80%-100%), and ability to cope with pain (0-6 rating vs 7-10 rating). Little variability was seen among patients’ responses, and dichotomizing allowed us to see the separa- tion between participant responses more clearly. In addition, the dichotomized groups were aligned with existing clini- cal practice goals for quality improvement of pain care out- comes at this organization. Data were analyzed using 2 approaches: (1) testing the entire participant sample’s demographics, pain care quality and pain experience outcome data, and unit-based monthly mean intervention adherence measures for the 6-component bundle and (2) testing the subsample of participants with individual-level intervention adherence data paired with pain care quality and pain experience outcome data. Entire Participant Sample Analysis (n=846) Demographic characteristics for the entire sample are reported as means and standard deviations for continuous measures and as frequencies and percentages for categor- ical measures. Chi-square tests were used for comparisons of the dichotomized 24-hour pain experience outcomes regarding time in severe pain, relief from pain, and ability to cope between participants reporting low vs high average pain. Additionally, all 3 dichotomized outcomes were com- pared via chi-square tests between groups defined by the dichotomized type of reported pain. A multinomial ordinal regression model incorporating an interrupted time series design was used to test for changes from preintervention to postintervention in means and time trends in PainCQ© scores across the sample and within each unit. Differences in changes from preintervention to postintervention in means and time trends in PainCQ© scores between units were also tested. Subsample Analysis (n=594) A subsample analysis was completed using the prein- tervention participant data (n=141) and data collected on postintervention participants (n=453) with individual paired data for intervention adherence for the bundle compo- nents, PainCQ© and pain experience outcomes. As previ- ously described, participants were categorized into 3 groups (Group 1 Preintervention, Group 2 Postintervention [receiv- ing 0-5 bundle components], and Group 3 Postinterven- tion [receiving all 6 bundle components]) for comparison. Sample size was determined from a power analysis of 82 Ochsner Journal Rice, KL PainCQ© scores. To achieve 80% power to detect differ- ences in PainCQ© scores between the 3 adherence groups, a total sample size of n=231 is sufficient. The power and sample size calculations are based on the expectation of observed means equal to 4.0, 4.5, and 5.0 for the preinter- vention, postintervention with partial intervention adherence, and postintervention with full adherence groups, respec- tively. A standard deviation of 1.0 was assumed for all partic- ipant groups, and the calculations were adjusted to account for multiple comparisons. Because of the non-normality of the actual observed PainCQ© scores in this study, the sub- sequently described group comparisons utilized nonpara- metric methods. Although less powerful than analogous parametric tests, we concluded that the amassed sample size of n=594 was sufficient to maintain adequate power. Using one-way ANOVA for continuous measures and chi- square tests for categorical measures, demographics and type of pain were compared. To test for group differences in the study outcomes, Kruskal-Wallis tests were used for distributions of PainCQ© scores and subscale scores, chi- square tests were used for associations with 24-hour pain care experience responses, and odds ratios (ORs) from a multinomial ordinal regression model were used for odds of higher PainCQ© scores. Finally, intervention adherence data for the 2 postintervention groups (n=453) were tested using chi-square tests for associations between exposure to individual bundle components and 24-hour pain experience outcomes. RESULTS Participant Characteristics A total of 1,290 patients met eligibility criteria over the course of the 34-month study period, with 856 (66.4%) con- senting (Figure 5). Ten of 856 participants withdrew without completing the survey because of a change in their medical condition (ie, pain, fatigue, nausea). Data from 846 partic- ipants were included in analyses. Participants’ self-reported demographic characteristics for the sample (n=846) included a mean age of 54.4 years (SD=14.4) and 50.9% male. Significantly more participants were white (66.1%), not Hispanic or Latino (94.4%), married/partnered (51.8%), and completed at least some college (54.3%) (Table 2). Of the 846 participants, 141 (16.7%) completed the PainCQ© surveys during the preintervention study period, July through October 2014. As previously stated, the 3 self-reported pain types (acute, chronic, or both) were only collected from postintervention participants, representing 704/846 (83.2%) of the sample, with the majority (413/704 [58.7%]) reporting acute pain compared to 125/704 (17.8%) reporting chronic pain and 166/704 (23.6%) with both acute and chronic pain (Table 2). A group comparison of all participants (n=846) based on reported 24-hour pain experience was completed. When 24- hour pain experience outcomes were dichotomized by low vs high average pain ratings, participants who reported a lower average daily pain score reported significantly less time in severe pain, greater pain relief from pharmacologic analgesia, and higher ability to cope with pain (Table 3). However, when 24-hour pain experience data were analyzed from the 704 postintervention participants from whom pain type was collected (Table 4), differing patterns of associa- tions were observed between participants reporting acute Figure 5. Participant flow chart. pain compared to participants who reported chronic or acute and chronic pain. Participants reporting acute pain alone had more reports of low average pain scores (22.3%), less time in severe pain (65.4%), and more relief from pharmacologic analgesia (56.7%) than those with chronic or both acute and chronic pain. No significant differences in ability to cope with pain based on type of pain were found. Pain Care Quality and Unit-Based Intervention Adherence Incorporating the interrupted time series design, an ordi- nal regression model was used to answer the research question, Does implementation of a unit-based stan- dardized bundle of evidence-based pain care interven- tions (BITE Pain TherapyTM) improve medical surgical patients’ perception of pain care quality over time? Fig- ure 6 illustrates that no significant changes occurred in trends of PainCQ-I© (F[1,836]<0.005; P=0.991) or PainCQ- N© (F[1,836]=0.08; P=0.776) scores over time or in mean PainCQ-I© (F[1,836]=0.07; P=0.792) or PainCQ-N© (F[1,836]=0.01; P=0.912) scores following implementation of the intervention. Three-Group Participant Findings Because the BITE Pain TherapyTM unit-based interven- tion adherence for the 6-component bundle failed to meet the monthly average goal of 80%, we were unable to test the hypotheses that bundle adherence had an effect on patients’ perception of pain care quality or pain experience outcomes. Faced with a mean unit-based adherence for the 6-component bundle that did not exceed zero percent during the first 7 months of the postintervention period, the protocol Volume 19, Number 2, Summer 2019 83 BITE Pain TherapyTM Table 2. Participant Characteristics Characteristic All Participants n=846 Mean age, years ± SD 54.4 ± 14.4 Sex Female 415 (49.1) Male 430 (50.9) Race Black or African American 248 (29.3) White 559 (66.1) Other 39 (4.6) Ethnic background Hispanic, Latino, or Spanish origin 47 (5.6) Not Hispanic or Latino 798 (94.4) Marital status Single 196 (23.2) Separated or divorced 127 (15.0) Widow or widower 85 (10.0) Married or partnered 438 (51.8) Education Technical school graduate and below 386 (45.7) Some college and above 459 (54.3) Paina Acute 413 (58.7) Chronic 125 (17.8) Acute and chronic 166 (23.6) aPain type was collected only on postintervention participants (n=704). Note: Data are reported as n (%) unless otherwise indicated. amendment afforded the opportunity to collect paired pain care quality, pain experience outcome, and bundle compo- nent adherence data beginning in the eighth month of the postintervention period. Intervention adherence data were collected on 453/705 (64.3%) postintervention participants who completed PainCQ© surveys. During the 30-month intervention period, participants (n=453) reported receiving a mean of 3.9 BITE Pain TherapyTM bundle components (median 4.0). However, only 65/453 (14.3%) reported receiv- ing all 6 bundle components (Figure 7). Audit data of each bundle component from the 453 participants revealed that 81.0% reported receiving pain education, 55.8% received both pain and coping with pain assessments, 83.8% experi- enced structured pain rounds, 38.8% had whiteboard com- munication of their comfort goal and next analgesic dose available, 96.0% were aware they were receiving phar- macologic analgesia, and 41.0% were offered the com- plementary therapy menu. The 2 bundle components that negatively impacted intervention fidelity were failure to update the whiteboard communication of the pain manage- ment plan and offering the complementary therapy menu. Table 5 describes the demographic characteristics of the 3 participant groups using the sample of 594: Group 1 Prein- tervention (no bundle), Group 2 Postintervention (offered 0-5 bundle components), and Group 3 Postintervention (offered all 6 bundle components). No differences (P>0.05) were Ta b le 3. 24 -H o u r P ai n Ex p er ie n ce O u tc o m e C o m p ar is o n s D ic h o to m iz ed b y Lo w vs H ig h A ve ra g e P ai n R at in g s (n =8 46 ) O u tc o m e Lo w A ve ra g e P ai n (0 -4 ra ti n g ) H ig h A ve ra g e P ai n (5 -1 0 ra ti n g ) M is si n g /U n kn o w n C h i- Sq u ar e (d f) a P V al u e Ti m e in se ve re p ai n 11 7. 3 (4 ) < 0. 00 1 0% -2 5% 12 9 (8 6. 0) 34 5 (4 9. 9) 1 (2 5. 0) 26 % -1 00 % 21 (1 4. 0) 34 4 (4 9. 7) 2 (5 0. 0) M is si n g /u n kn o w n 0 (0 .0 ) 3 (0 .4 ) 1 (2 5. 0) A m o u n t o fr el ie ff ro m p h ar m ac o lo g ic an al g es ia 39 .6 (4 ) < 0. 00 1 0% -7 5% 32 (2 1. 3) 33 7 (4 8. 7) 2 (5 0. 0) 80 % -1 00 % 10 6 (7 0. 7) 33 1 (4 7. 8) 2 (5 0. 0) M is si n g /u n kn o w n 12 (8 .0 ) 24 (3 .5 ) 0 (0 .0 ) A ve ra g e ab ili ty to co p e w it h p ai n 11 .1 (4 ) 0. 00 5 Lo w (0 -6 ra ti n g ) 39 (2 6. 0) 27 8 (4 0. 2) 2 (5 0. 0) H ig h (7 -1 0 ra ti n g ) 10 9 (7 2. 7) 40 9 (5 9. 1) 2 (5 0. 0) M is si n g /u n kn o w n 2 (1 .3 ) 5 (0 .7 ) 0 (0 .0 ) a Te st st a ti st ic s a n d P va lu e s fr o m c h i- sq u a re te st s fo r a ss o c ia ti o n . N o te s: T h e M is si n g /U n kn o w n c o lu m n la b e lr e fe rs to u n kn o w n re sp o n se s fo r ra ti n g o f a ve ra g e p a in ; th e M is si n g /u n kn o w n ro w la b e ls re fe r to u n kn o w n re sp o n se s fo r ra ti n g s o f ti m e in se ve re p a in , a m o u n t o f p a in re lie f fr o m p h a rm a c o lo g ic a n a lg e si a , o r a ve ra g e a b ili ty to c o p e w it h p a in . D a ta a re re p o rt e d a s n (% ). B o ld d e n o te s st a ti st ic a ls ig n ifi c a n c e . d f, d e g re e s o f fr e e d o m . 84 Ochsner Journal Rice, KL Table 4. 24-Hour Pain Experience Outcome Comparison by Type of Pain (n=704) Outcome Acute Pain Chronic Pain Acute and Chronic Pain Chi-Square (df)a P Value Average pain 18.3 (4) 0.001 Low (0-4 rating) 92 (22.3) 13 (10.4) 16 (9.6) High (5-10 rating) 319 (77.2) 111 (88.8) 149 (89.8) Missing/unknown 2 (0.5) 1 (0.8) 1 (0.6) Time in severe pain 38.3 (4) <0.001 0%-25% 270 (65.4) 55 (44.0) 69 (41.6) 26%-100% 140 (33.9) 69 (55.2) 97 (58.4) Missing/unknown 3 (0.7) 1 (0.8) 0 (0.0) Amount of relief from pharmacologic analgesia 14.2 (4) 0.007 0%-75% 165 (40.0) 64 (51.2) 87 (52.4) 80%-100% 234 (56.7) 55 (44.0) 69 (41.6) Missing/unknown 14 (3.4) 6 (4.8) 10 (6.0) Average ability to cope with pain 5.2 (4) 0.267 Low (0-6 rating) 140 (33.9) 49 (39.2) 69 (41.6) High (7-10 rating) 270 (65.4) 75 (60.0) 94 (56.6) Missing/unknown 3 (0.7) 1 (0.8) 3 (1.8) aTest statistics and P values from chi-square tests for association. Notes: Data are reported as n (%). Bold denotes statistical significance. df, degrees of freedom. seen in age, sex, race, ethnicity, marital status, or highest level of education among the 3 groups. In addition, we found no difference in the distribution of pain types between the 2 postintervention groups. This 3-group analysis of the preintervention participants and 2 postintervention participant groups identified signifi- cant (P<0.05) differences between groups for total PainCQ- I© and PainCQ-N© scores, as well as all subscale scores (Table 6). Participants in Group 3 Postintervention who were offered all 6 bundle components had a higher percep- tion of pain care quality compared to either the Group 1 Preintervention participants or the Group 2 Postintervention participants. Regression analysis of ordered multinomial PainCQ-I© and PainCQ-N© scores by group suggests that the odds of higher pain care quality scores were not statistically different between Group 2 and Group 1 (Table 7). However, Group 3 had significantly higher odds of higher scores for both the PainCQ-I© (OR >2.5) and PainCQ-N© (OR >3.8) surveys vs both Group 1 and Group 2 (Table 7). We found no significant differences (P>0.05) between Group 1 Preintervention participants and participants in the 2 postintervention participant groups for 24-hour pain out- comes (Table 8). Although the majority of participants in all 3 groups reported a high average daily pain score (score >5), the majority also reported less time in severe pain (<26% of the time) and higher abilities to cope with pain (score >6). In contrast, reports of the percentage of pain relief from phar- macologic analgesia for the 3 groups were variable. Even though participants who received all 6 bundle com- ponents did not demonstrate a significant impact on 24-hour pain experience outcomes, a secondary analysis of each bundle component did identify the following findings. When each bundle component was tested for an association with each of the 24-hour pain experience outcomes, one bun- dle component significantly improved two of the four 24- hour pain outcomes (Table 9). Participants who received the structured Pain Rounds bundle component vs those who did not reported significantly less time in severe pain and a higher ability to cope with pain. DISCUSSION To our knowledge, this study is the first to test the effect of a patient-centered bundled pain management interven- tion on medical surgical patients’ perception of pain care quality and 24-hour pain experience outcomes. Yet because unit-based intervention fidelity failed to meet the goal of 80% adherence with the BITE Pain TherapyTM 6-component bundle, we were unable to determine an effect of the unit- based intervention on patients’ perception of pain care qual- ity and 24-hour pain experience outcomes comparing the preintervention to postintervention periods as initially pro- posed. However, the sample size was sufficient to complete a 3-group analysis that allowed us to compare participants’ perception of pain care quality and 24-hour pain experience outcomes with confirmed intervention adherence in a sub- sample of 70.2% (594/846) of participants. This subsample was representative of the patient populations cared for on all 3 participating units for sex, age, and ethnicity, with no significant differences in the distribution of participant char- acteristics among the 3 groups. Our subsample findings support that participants receiv- ing the 6-component bundle comprising the BITE Pain TherapyTM intervention reported significantly higher levels of pain care quality delivered by both nurses and interdis- ciplinary care teams during hospitalization. In contrast, no Volume 19, Number 2, Summer 2019 85 BITE Pain TherapyTM Figure 6. Run chart showing mean monthly unit-based intervention adherence with the 6-component bundle and PainCQ© scores for interdisciplinary and nursing surveys during the 34-month study period. PainCQ-I, Pain Care Quality-Interdisciplinary; PainCQ-N, Pain Care Quality-Nursing. differences in perception of pain care quality were detected between participants in the preintervention group and partic- ipants in the postintervention group that did not receive all 6 bundle components. Therefore, this study provides support that using all 6 components comprising BITE Pain TherapyTM significantly improved the perception of pain care quality in the medical surgical patients who participated in this study. No relationships were identified between the preinterven- tion and 2 postintervention groups for average pain score, time in severe pain, amount of pain relief from pharmacologic analgesia, or average ability to cope with pain. Overall, the majority of participants in all 3 groups reported an average 24-hour pain rating in the moderate to severe range (5-10 rating), yet reports of less percentage of time in severe pain (0%-25%) vs more time (26%-100%) in severe pain were Figure 7. BITE Pain Therapy TM (Bundling Interventions to Enhance Pain Care Quality) bundle adherence for all 6 components (n=453). 86 Ochsner Journal Rice, KL Ta b le 5. P ar ti ci p an t C h ar ac te ri st ic s an d B iv ar ia te C o m p ar is o n s fo r P re in te rv en ti o n an d Po st in te rv en ti o n G ro u p s (n =5 94 ) G ro u p 1 G ro u p 2 G ro u p 3 P re in te rv en ti o n Po st in te rv en ti o n (0 -5 b u n d le Po st in te rv en ti o n (6 b u n d le Te st C h ar ac te ri st ic (n o b u n d le )n =1 41 co m p o n en ts )n =3 88 co m p o n en ts )n =6 5 St at is ti ca P V al u e M ea n ag e, ye ar s ± SD 55 .5 ± 15 .0 55 .9 ± 14 .1 51 .5 ± 15 .7 F( 2, 59 1) =2 .5 3 0. 08 1 Se x χ 2 (2 )= 4. 38 0. 11 2 Fe m al e 83 (5 8. 9) 18 9 (4 8. 7) 32 (4 9. 2) M al e 58 (4 1. 1) 19 9 (5 1. 3) 33 (5 0. 8) R ac e χ 2 (4 )= 1. 53 0. 82 1 B la ck o rA fr ic an A m er ic an 45 (3 1. 9) 10 9 (2 8. 1) 21 (3 2. 3) W h it e 89 (6 3. 1) 26 4 (6 8. 0) 41 (6 3. 1) O th er 7 (5 .0 ) 15 (3 .9 ) 3 (4 .6 ) Et h n ic b ac kg ro u n d χ 2 (2 )= 1. 28 0. 86 4 H is p an ic ,L at in o, o rS p an is h o ri g in 9 (6 .4 ) 18 (4 .6 ) 4 (6 .2 ) N o t H is p an ic o rL at in o 13 2 (9 3. 6) 36 9 (9 5. 1) 61 (9 3. 8) M is si n g /u n kn o w n 0 (0 .0 ) 1 (0 .3 ) 0 (0 .0 ) M ar it al st at u s χ 2 (6 )= 4. 47 0. 61 4 Si n g le 33 (2 3. 4) 80 (2 0. 6) 17 (2 6. 2) Se p ar at ed o rd iv o rc ed 20 (1 4. 2) 62 (1 6. 0) 5 (7 .7 ) W id o w o rw id o w er 20 (1 4. 2) 50 (1 2. 9) 7 (1 0. 8) M ar ri ed o rp ar tn er ed 68 (4 8. 2) 19 6 (5 0. 5) 36 (5 5. 4) Ed u ca ti o n χ 2 (2 )= 0. 03 0. 98 7 Te ch n ic al sc h o o lg ra d u at e an d b el o w 64 (4 5. 4) 17 5 (4 5. 1) 30 (4 6. 2) So m e co lle g e an d ab o ve 77 (5 4. 6) 21 3 (5 4. 9) 35 (5 3. 8) Pa in χ 2 (1 )= 1. 40 0. 50 9 A cu te N o t co lle ct ed 22 7 (5 8. 5) 43 (6 6. 2) C h ro n ic N o t co lle ct ed 66 (1 7. 0) 9 (1 3. 8) A cu te an d ch ro n ic N o t co lle ct ed 95 (2 4. 5) 13 (2 0. 0) a Te st st a ti st ic s a n d P va lu e s fr o m o n e -w a y A N O V A F -t e st fo r a g e c o m p a ri so n a n d c h i- sq u a re te st s fo r a ss o c ia ti o n fo r a ll c a te g o ri c a lv a ri a b le c o m p a ri so n s. N o te : D a ta a re re p o rt e d a s n (% ) u n le ss o th e rw is e in d ic a te d . Volume 19, Number 2, Summer 2019 87 BITE Pain TherapyTM Ta b le 6. P re in te rv en ti o n an d Po st in te rv en ti o n G ro u p C o m p ar is o n s o fP ai n C Q © an d Su b sc al e Sc o re s (n =5 94 ) G ro u p 1 P re in te rv en ti o n G ro u p 2 Po st in te rv en ti o n G ro u p 3 Po st in te rv en ti o n C h i- Sq u ar e Su rv ey /S u b sc al e (n o b u n d le )n =1 41 (0 -5 b u n d le co m p o n en ts )n =3 88 (6 b u n d le co m p o n en ts )n =6 5 (d f) a P V al u e Pa in C Q -I n te rd is ci p lin ar y© su rv ey 4. 5 (3 .7 -5 .3 ) 4. 5 (3 .7 -5 .5 ) 5. 3 (4 .8 -5 .8 ) 19 .8 (2 ) < 0. 00 1 Su b sc al e 1 – Pa rt n er sh ip w it h th e H ea lt h C ar e Te am 5. 7 (5 .0 -6 .0 ) 5. 7 (5 .0 -6 .0 ) 6. 0 (5 .7 -6 .0 ) 18 .9 (2 ) < 0. 00 1 Su b sc al e 2 – C o m p re h en si ve In te rd is ci p lin ar y Pa in C ar e 3. 7 (2 .3 -5 .0 ) 4. 0 (2 .7 -5 .0 ) 4. 7 (4 .0 -5 .7 ) 14 .9 (2 ) < 0. 00 1 Pa in C Q -N u rs in g © su rv ey 5. 2 (4 .8 -5 .7 ) 5. 4 (4 .6 -5 .8 ) 5. 9 (5 .3 -6 .0 ) 25 .3 (2 ) < 0. 00 1 Su b sc al e 1 – B ei n g Tr ea te d R ig h t 6. 0 (5 .5 -6 .0 ) 6. 0 (5 .5 -6 .0 ) 6. 0 (6 .0 -6 .0 ) 14 .0 (2 ) < 0. 00 1 Su b sc al e 2 – C o m p re h en si ve N u rs in g Pa in C ar e 4. 8 (3 .5 -5 .6 ) 4. 8 (3 .5 -5 .8 ) 5. 8 (4 .8 -6 .0 ) 28 .9 (2 ) < 0. 00 1 Su b sc al e 3 – Effi ca cy o fP ai n M an ag em en t 5. 7 (5 .0 -6 .0 ) 5. 7 (5 .0 -6 .0 ) 6. 0 (5 .3 -6 .0 ) 8. 6 (2 ) 0. 01 4 a Te st st a ti st ic s a n d P va lu e s fr o m c h i- sq u a re te st s fo r a ss o c ia ti o n . N o te s: D a ta a re re p o rt e d a s m e d ia n (2 5 th p e rc e n ti le -7 5 th p e rc e n ti le ). B o ld d e n o te s st a ti st ic a ls ig n ifi c a n c e . d f, d e g re e s o f fr e e d o m ; P a in C Q © , p a in c a re q u a lit y. Table 7. Regression Analysis of Ordered Multinomial PainCQ© Scores by Preintervention and Postintervention Group (n=594) Survey/Comparison Groups Odds Ratioa (95% CI) PainCQ-Interdisciplinary© survey Group 2 Postinterventionb vs Group 1 Preinterventionc 1.04 (0.73-1.47) Group 3 Postinterventiond vs Group 1 Preinterventionc 2.61 (1.54-4.42) Group 3 Postinterventiond vs Group 2 Postinterventionb 2.52 (1.57-4.03) PainCQ-Nursing© survey Group 2 Postinterventionb vs Group 1 Preinterventionc 0.99 (0.70-1.42) Group 3 Postinterventiond vs Group 1 Preinterventionc 3.82 (2.06-7.09) Group 3 Postinterventiond vs Group 2 Postinterventionb 3.84 (2.17-6.80) aOdds ratios represent odds of a higher score on the PainCQ© scale. bGroup 2 Postintervention (0-5 bundle components). cGroup 1 Preintervention (no bundle). dGroup 3 Postintervention (6 bundle components). CI, confidence interval; PainCQ©, pain care quality. almost equally split. The incongruence between the major- ity of participants’ reports of moderate to severe pain and less percentage of time in severe pain may be explained by the dichotomization of these measures. Even though others have reported the validity of categorizing numerical pain rat- ings into 3 groups (mild, moderate, and severe pain),50,51 we chose to categorize pain ratings into 2 groups based on our institution’s quality improvement goals related to pain. The accuracy of participant recall could also have biased pain- related outcome measurement and contributed to the incon- gruence between average 24-hour pain ratings and percent- age of time in severe pain. However, other studies support the validity of patient recall related to reporting average pain scores for both 24-hour52,53 and 1-week time periods.54 In addition, we found no differences between groups in participants’ reports of the amount of relief from pharma- cologic analgesia. Fifty-seven percent of the preinterven- tion group reported �80% relief from pharmacologic anal- gesia compared to an almost equal split between <80% and �80% in the 2 postintervention groups. While the latter finding was not significant, organization-wide strategies to promote adjunctive nonpharmacologic pain management to reduce opioid use were launched at the same time that this research study began. Therefore, pharmacologic analgesia alone would have been the mainstay of pain management during the preintervention period and may have contributed to reports of �80% relief from analgesics. Nevertheless, we did not measure opioid use, so we are unable to determine if the differences in opioid administration differed between the preintervention or postintervention groups and contributed to reports of increased pain relief from pharmacologic anal- gesia in the preintervention group. The bundled intervention did not have a significant effect on participants’ ability to cope with pain. Although the major- 88 Ochsner Journal Rice, KL Ta b le 8. P re in te rv en ti o n an d Po st in te rv en ti o n G ro u p C o m p ar is o n o fD is tr ib u ti o n s o fD ic h o to m iz ed 24 -H o u r P ai n Ex p er ie n ce O u tc o m es (n =5 94 ) G ro u p 1 P re in te rv en ti o n G ro u p 2 Po st in te rv en ti o n G ro u p 3 Po st in te rv en ti o n C h i- Sq u ar e O u tc o m e (n o b u n d le )n =1 41 (0 -5 b u n d le co m p o n en ts )n =3 88 (6 b u n d le co m p o n en ts )n =6 5 (d f) a P V al u e A ve ra g e p ai n 4. 9 (4 ) 0. 29 6 Lo w (0 -4 ra ti n g ) 29 (2 0. 6) 72 (1 8. 6) 7 (1 0. 8) H ig h (5 -1 0 ra ti n g ) 11 2 (7 9. 4) 31 4 (8 0. 9) 57 (8 7. 7) M is si n g /u n kn o w n 0 (0 .0 ) 2 (0 .5 ) 1 (1 .5 ) Ti m e in se ve re p ai n 1. 9 (4 ) 0. 75 4 0% -2 5% 81 (5 7. 4) 21 5 (5 5. 4) 37 (5 6. 9) 26 % -1 00 % 60 (4 2. 6) 17 0 (4 3. 8) 27 (4 1. 5) M is si n g /u n kn o w n 0 (0 .0 ) 3 (0 .8 ) 1 (1 .5 ) A m o u n t o fr el ie ff ro m p h ar m ac o lo g ic an al g es ia 5. 6 (4 ) 0. 23 3 0% -7 5% 55 (3 9. 0) 18 2 (4 6. 9) 33 (5 0. 8) 80 % -1 00 % 80 (5 6. 7) 19 2 (4 9. 5) 32 (4 9. 2) M is si n g /u n kn o w n 6 (4 .3 ) 14 (3 .6 ) 0 (0 .0 ) A ve ra g e ab ili ty to co p e w it h p ai n 7. 0 (4 ) 0. 13 7 Lo w (0 -6 ra ti n g ) 61 (4 3. 3) 13 4 (3 4. 5) 22 (3 3. 8) H ig h (7 -1 0 ra ti n g ) 80 (5 6. 7) 24 7 (6 3. 7) 43 (6 6. 2) M is si n g /u n kn o w n 0 (0 .0 ) 7 (1 .8 ) 0 (0 .0 ) a Te st st a ti st ic s a n d P va lu e s fr o m c h i- sq u a re te st s fo r a ss o c ia ti o n . N o te : D a ta a re re p o rt e d a s n (% ). d f, d e g re e s o f fr e e d o m . Volume 19, Number 2, Summer 2019 89 BITE Pain TherapyTM Table 9. Comparison of 24-Hour Pain Experience Outcomes by Exposure to Each Bundle Component Component Outcome Yes No Chi-Square (df)a P Value Component 1. Pain Education Average pain 0.42 (1) 0.519 Low (0-4 rating) 18.3 15.3 High (5-10 rating) 81.7 84.7 Time in severe pain 0.12 (1) 0.729 0%-25% 56.7 54.7 26%-100% 43.3 45.3 Amount of relief from pharmacologic analgesia 0.23 (1) 0.229 0%-75% 47.5 54.8 80%-100% 52.5 45.2 Average ability to cope with pain 1.04 (1) 0.307 Low (0-6 rating) 33.7 39.5 High (7-10 rating) 66.3 60.5 Component 2. Pain and Coping Average pain 2.13 (1) 0.144 With Pain Assessment Low (0-4 rating) 15.4 20.7 High (5-10 rating) 84.6 79.3 Time in severe pain 0.00 (1) 0.963 0%-25% 56.4 56.6 26%-100% 43.6 43.4 Amount of relief from pharmacologic analgesia 0.05 (1) 0.817 0%-75% 48.4 49.5 80%-100% 51.6 50.5 Average ability to cope with pain 0.52 (1) 0.472 Low (0-6 rating) 33.5 36.7 High (7-10 rating) 66.5 63.3 Component 3. Structured Pain Average pain 1.49 (1) 0.222 Rounds Low (0-4 rating) 18.7 12.7 High (5-10 rating) 81.3 87.3 Time in severe pain 6.32 (1) 0.012 0%-25% 59.1 42.9 26%-100% 40.9 57.1 Amount of relief from pharmacologic analgesia 2.76 (1) 0.097 0%-75% 47.0 57.8 80%-100% 53.0 42.2 Average ability to cope with pain 6.10 (1) 0.014 Low (0-6 rating) 32.6 47.9 High (7-10 rating) 67.4 52.1 Component 4. Whiteboard Average pain 2.69 (1) 0.101 Communication Low (0-4 rating) 14.0 20.1 High (5-10 rating) 86.0 79.9 Time in severe pain 0.06 (1) 0.808 0%-25% 55.6 56.8 26%-100% 44.4 43.2 Amount of relief from pharmacologic analgesia 2.43 (1) 0.119 0%-75% 53.4 45.8 80%-100% 46.6 54.2 90 Ochsner Journal Rice, KL Table 9. Continued Component Outcome Yes No Chi-Square (df)a P Value Average ability to cope with pain 0.29 (1) 0.593 Low (0-6 rating) 33.3 35.8 High (7-10 rating) 66.7 64.2 Component 5. Pharmacologic Average pain 3.78 (1) 0.052 Analgesia Low (0-4 rating) 18.3 0.0 High (5-10 rating) 81.7 100.0 Time in severe pain 0.07 (1) 0.788 0%-25% 56.2 52.9 26%-100% 43.8 47.1 Amount of relief from pharmacologic analgesia 1.16 (1) 0.282 0%-75% 48.8 62.5 80%-100% 51.2 37.5 Average ability to cope with pain 1.26 (1) 0.262 Low (0-6 rating) 33.9 47.1 High (7-10 rating) 66.1 52.9 Component 6. Nonpharmacologic Average pain 0.71 (1) 0.399 Therapy Menu Low (0-4 rating) 15.9 19.0 High (5-10 rating) 84.1 81.0 Time in severe pain 0.26 (1) 0.613 0%-25% 58.0 55.6 26%-100% 42.0 44.4 Amount of relief from pharmacologic analgesia 0.24 (1) 0.626 0%-75% 50.3 47.9 80%-100% 49.7 52.1 Average ability to cope with pain 3.21 (1) 0.073 Low (0-6 rating) 29.7 37.9 High (7-10 rating) 70.3 62.1 aTest statistics and P values from chi-square tests for association. Notes: Data are reported as percentages. Bold denotes statistical significance. ity of participants in all 3 groups reported higher ability to cope with pain (7-10 rating) vs low ability (0-6 rating), both postintervention groups had slightly more reports of higher ability to cope compared to the preintervention group. While the nonpharmacologic menu options were included as a bundle component because of their potential impact on coping with pain, many factors contribute to an indi- vidual’s ability to cope with pain. Factors such as spiritual beliefs and prior experience with using distraction in deal- ing with pain may have impacted responses to this question by participants in all 3 groups. However, information regard- ing prior knowledge and/or utilization of nonpharmacologic adjunctive therapies was not measured in the preinterven- tion or postintervention groups. Hence, we were unable to determine whether our study provided participants with a first encounter with nonpharmacologic pain management strategies. Although the BITE Pain TherapyTM 6-component bun- dle failed to impact any of the 24-hour pain experience outcomes, one individual bundle component did have an impact. Interestingly, the only bundle component associated with significantly less time in severe pain and higher abil- ity to cope with pain was structured pain rounds. The fre- quent nurse/patient interaction facilitated by structured pain rounds may result in better pain management. Mitchell et al synthesized the evidence of 16 studies examining the effect of hourly rounding on patient satisfaction with nurs- ing care.55 They concluded that despite little consistency in how hourly rounding is measured, moderate-strength evi- dence indicates that hourly rounding programs improved patients’ perception of nursing responsiveness to requests for assistance. In addition, results from an hourly round- ing best-practice implementation project on a 28-bed med- ical surgical unit showed a 5% increase in nurse commu- nication and an 11% increase in pain management scores when the hourly rounding compliance rate increased to 64% from zero at baseline.56 Hence, frequent rounding about pain that promotes nursing responsiveness to patient needs may have contributed to increasing the perception of less time in severe pain and a higher ability to cope with pain. Volume 19, Number 2, Summer 2019 91 BITE Pain TherapyTM However, structured pain rounds did not have a relation- ship with participants’ reports of less time in severe pain or lower average 24-hour pain scores. Despite reports by Jensen et al53 regarding the validity of 24-hour pain score recall, challenges in accurately capturing patients’ percep- tions of postoperative pain using the faces scale exist. Anecdotally, many patients struggle with using the 0-10 numeric scale to communicate their level of pain, partic- ularly when they are aware that a higher score might get them a stronger medication. Similarly, nurses may discount patients’ reported pain scores that can lead to undertreat- ment or overtreatment of pain.51 Others have suggested that using a numeric rating scale that integrates a functional assessment of pain-related impact on activities may be a more appropriate measure of patients’ self-reported pain.57 Clearly, opportunities exist in identifying effective strategies to comprehensively target pain management and in adopt- ing reliable and valid multidimensional outcome measures to drive quality improvement. Even though the findings from this study support that the BITE Pain TherapyTM bundled intervention improved partici- pants’ perception of pain care quality, the intervention adher- ence did not support sustainability of the unit-based project. Project sustainability requires continued use of intervention components with sufficient intensity to sustain achievement of program goals and outcomes.58,59 Therefore, identifying pragmatic methods to both measure adherence and cap- ture facilitators and barriers to intervention fidelity is crit- ical. In this study, intervention adherence was measured using patient recall for a 24-hour period rather than real- time methods to capture bundle component adherence and patient-related responses to individual bundle compo- nents. Although multiple strategies were used to improve unit-based intervention adherence—weekly communication of adherence rates, communication huddles, and solicit- ing information about adherence facilitators and obstacles— several factors during the 30-month intervention period con- tributed to failed intervention fidelity: changes in unit nurs- ing leadership, high nurse turnover, and nurses’ perception of increased burden associated with delivering nonpharma- cologic menu options. The findings of a qualitative study describing nurse leaders’ perceptions of facilitators and obstacles to unit-based pain improvement projects are sim- ilar to what we uncovered.60 Tavernier and colleagues60 concluded that sustainable improvement related to pain management projects required overcoming the pervasive barriers of dynamic organizational change and lack of staff involvement. LIMITATIONS Major limitations of the study are the failure of interven- tion fidelity, a sample from surgical units from one facility, and a sampling plan that limited recruitment to one day each month to capture the primary endpoint of a unit-based intervention study. In addition, data were not collected on the specific nonpharmacologic menu options selected and whether the participant perceived a benefit. IMPLICATIONS The BITE Pain TherapyTM intervention is pragmatic and can be easily tailored to include nonpharmacologic therapies that are low cost, easily accessible, and acceptable to a vari- ety of culturally diverse populations in different acute care settings. Since the inception of our project, the American Pain Society (APS) published guidelines for the management of postoperative patients61 that includes recommendations for behavioral/cognitive therapies such as guided imagery and music therapy as adjuncts to multimodal pharmaco- logic pain management. In addition, the Joint Commission10 revised pain assessment and management standards effec- tive January 1, 2018, to include involving patients in devel- oping pain management plans that include setting realistic expectations and measurable goals and providing nonphar- macologic options for inpatient pain treatment. All 6 bun- dle components in our patient-centered, multidisciplinary BITE Pain TherapyTM intervention address the APS guide- lines and Joint Commission recommendations that focus on effective pain management. All of the BITE Pain TherapyTM bundle components are congruent with the standard of nursing care. Offering adjunctive complementary therapy options such as aromatherapy, distraction activities (ie, puz- zles, games), and individual handheld massagers is feasi- ble on medical surgical units. In addition, opportunities to provide pet therapy and music therapy may be available by using institutional volunteer services. Our findings identified that postintervention participants with acute pain alone, irrespective of whether they received all bundle components or not, reported less time in severe pain and more relief from pharmacologic analgesia. This finding is consistent with the findings of the National Database of Nursing Quality Indicators study62 and suggests that healthcare providers do a better job with acute pain in the inpatient setting. Therefore, interprofessional educa- tion about comprehensively assessing and effectively man- aging both acute and chronic pain in the hospitalized adult is needed. Finally, additional research is warranted to replicate this study at other types of inpatient facilities and in dif- ferent patient populations. Studies should be designed to test care delivery processes that deliver the interven- tion without increasing nurses’ burden of work. In addi- tion, studies should explore strategies to assist healthcare providers to identify which patients will benefit from the bun- dled pain management strategies and/or individual bundle components. CONCLUSION Findings from this study support that medical surgical patients participating in this study who received all 6 com- ponents of the BITE Pain TherapyTM intervention reported significantly higher levels of perceived pain care quality com- pared to those who did not receive all bundle components. Therefore, a bundled approach to pain management may be more beneficial than unstandardized strategies. Challenges exist in implementing the complete bundle to all patients in pain. ACKNOWLEDGMENTS The research methods and limited findings from this study were disseminated as a podium presentation, “BITE Pain Therapy: Bundling of Interventions to Enhance Pain Care Quality,” at the 2018 American Nurses Association Quality 92 Ochsner Journal Rice, KL and Innovation Summit in Orlando, FL in March 2018. The authors have no financial or proprietary interest in the sub- ject matter of this article. REFERENCES 1. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming, Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011. 2. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012 Aug;13(8):715-724. doi: 10.1016/j.jpain.2012.03.009. 3. HCAHPS three-state pilot study analysis results. CAHPS II Investigators & AHRQ. www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/Hospital QualityInits/downloads/Hospital3State_Pilot_Analysis_ Final200512.pdf. Published December 22, 2003. Accessed November 1, 2018. 4. Glowacki D. Effective pain management and improvements in patients’outcomes and satisfaction. Crit Care Nurse. 2015 Jun;35(3):33-41; quiz 43. doi: 10.4037/ccn2015440. 5. Simmons SF, Schnelle JF, Saraf AA, et al. Pain and satisfaction with pain management among older patients during the transition from acute to skilled nursing care. Gerontologist. 2016 Dec;56(6):1138-1145. doi: 10.1093/geront/gnv058. 6. Hanna MN, González-Fernández M, Barrett AD, Williams KA, Pronovost P. Does patient perception of pain control affect patient satisfaction across surgical units in a tertiary teaching hospital? Am J Med Qual. 2012 Sep-Oct;27(5):411-416. doi: 10.1177/1062860611427769. 7. Voscopoulos C, Lema M. When does acute pain become chronic. Br J Anaesth. 2010 Dec;105 Suppl 1:i69-i85. doi: 10.1093/bja/aeq323. 8. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003 Aug;97(2):534-540. 9. Hospital value-based purchasing. Centers for Medicare and Medicaid Services. ICN 907664. www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664. pdf. Published September 2017. Accessed November 1, 2018. 10. Joint Commission. Joint Commission enhances pain assessment and management requirements for accredited hospitals. The Joint Commission Perspectives’: The Official Newsletter of The Joint Commission. 37(7). www. jointcommission.org/assets/1/18/Joint_Commission_Enhances _Pain_Assessment_and_Management_Requirements_for _Accredited_Hospitals1.PDF. Published July 2017. Accessed November 1, 2018. 11. Sinatra R. Causes and consequences of inadequate management of acute pain. Pain Med. 2010 Dec;11(12):1859-1871. doi: 10.1111/j.1526-4637.2010.00983.x. 12. Carver CS. Stress, coping, and health. In: Friedman HS, Silver RC, eds. Foundations of Health Psychology. New York, NY: Oxford University Press; 2007:117-144. 13. Koolhaas JM, Bartolomucci A, Buwalda B, et al. Stress revisited: a critical evaluation of the stress concept. Neurosci Biobehav Rev. 2011 Apr;35(5):1291-1301. doi: 10.1016/j.neubiorev.2011.02.003. 14. Oxford Centre for Evidence-Based Medicine – Levels of Evidence. Centre for Evidence Based Medicine. www.cebm.net/ 2009/06/oxford-centre-evidence-based-medicine-levels- evidence-march-2009/. Published March 2009. Accessed November 1, 2018. 15. Goldberg GR, Morrison RS. Pain management in hospitalized cancer patients: a systematic review. J Clin Oncol. 2007 May 1;25(13):1792-1801. doi: 10.1200/JCO.2006.07.9038. 16. Crowe L, Chang A, Fraser J, Gaskill D, Nash R, Wallace K. Systematic review of the effectiveness of nursing interventions in reducing or relieving post-operative pain. Int J Evid Based Healthc. 2008 Dec;6(4):396-430. doi: 10.1111/j.1744-1609.2008.00113.x. 17. Castillo-Bueno MD, Moreno-Pina JD, Martínez-Puente MV, et al. Effects of nursing interventions for adult patients experiencing chronic pain: a systematic review. JBI Libr Syst Rev. 2010;8(28):1112-1168. 18. Cole LC, LoBiondo-Wood G. Music as adjuvant therapy in control of pain symptoms in hospitalized adults: a systematic review. Pain Manag Nurs. 2014 Mar;15(1):406-425. doi: 10.1016/j.pmn.2012.08.010. 19. Sjöling M, Nordahl G, Olofsson N, Asplund K. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management. Patient Educ Couns. 2003 Oct;51(2):169-176. 20. Garra D, Singer AJ, Leno R, et al. Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy. Acad Emerg Med. 2010 May;17(5):484-489. doi: 10.1111/j.1553-2712.2010.00735.x. 21. Gutgsell KJ, Schluchter M, Margevicius S, et al. Music therapy reduces pain in palliative care patients: a randomized controlled trial. J Pain Symptom Manage. 2013 May;45(5):822-831. doi: 10.1016/j.jpainsymman.2012.05.008. 22. Hausmann LR, Parks A, Youk AO, Kwoh CK. Reduction of bodily pain in response to an online positive activities intervention. J Pain. 2014 May;15(5):560-567. doi: 10.1016/j.jpain.2014.02.004. 23. Jameson E, Trevena J, Swain N. Electronic gaming as pain distraction. Pain Res Manag. 2011 Jan-Feb;16(1):27-32. 24. Olapour A, Behaeen K, Akhondzadeh R, Soltani F, Al Sadat Razavi F, Bekhradi R. The effect of inhalation of aromatherapy blend containing lavender essential oil on cesarian postoperative pain. Anesth Pain Med. 2013 Summer;3(1):203-207. doi: 10.5812/aapm.9570. 25. Olrich T, Kalman M, Nigolian C. Hourly rounding: a replication study. Medsurg Nurs. 2012 Jan-Feb;21(1):23-36. 26. Marcus DA, Bernstein CD, Constantin JM, Kunkel FA, Breuer P, Hanlon RB. Animal-assisted therapy at an outpatient pain management clinic. Pain Med. 2012 Jan;13(1):45-57. doi: 10.1111/j.1526-4637.2011.01294.x. 27. Sauaia A, Min SJ, Leber C, Erbacher K, Abrams F, Fink R. Postoperative pain management in elderly patients: correlation between adherence to treatment guidelines and patient satisfaction. J Am Geriatr Soc. 2005 Feb;53(2):274-282. doi: 10.1111/j.1532-5415.2005.53114.x. 28. Archer KR, Castillo RC, Wegener ST, Abraham CM, Obremskey WT. Pain and satisfaction in hospitalized trauma patients: the importance of self-efficacy and psychological distress. J Trauma Acute Care Surg. 2012 Apr;72(4):1068-1077. doi: 10.1097/TA.0b013e3182452df5. 29. Baldacchino D, Torskenaes K, Kalfoss M, et al. Spiritual coping in rehabilitation-a comparative study: part 2. Br J Nurs. 2013 Apr 11-24;22(7):402-408. doi: 10.12968/bjon.2013.22.7.402. 30. Chan S, Hadjistavropoulos T, Carleton RN, Hadjistavropoulos H. Predicting adjustment to chronic pain in older adults. Can J Behav Sci. 2012 Jul;44(3):192-199. doi: 10.1037/a0028370. 31. Heutink M, Post MW, Overdulve CW, et al. Which pain coping strategies and cognitions are associated with outcomes of a Volume 19, Number 2, Summer 2019 93 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/Hospital3State_Pilot_Analysis_Final200512.pdf http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/Hospital3State_Pilot_Analysis_Final200512.pdf http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/Hospital3State_Pilot_Analysis_Final200512.pdf http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/Hospital3State_Pilot_Analysis_Final200512.pdf http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf http://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF http://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF http://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF http://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF http://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ BITE Pain TherapyTM cognitive behavioral intervention for neuropathic pain after spinal cord injury? Top Spinal Cord Inj Rehabil. 2013 Fall;19(4):330-340. doi: 10.1310/sci1904-330. 32. Ramírez-Maestre C, Esteve R, López AE. Cognitive appraisal and coping in chronic pain patients. Eur J Pain. 2008 Aug;12(8):749-756. doi: 10.1016/j.ejpain.2007.11.004. 33. Stoffel M, Reis D, Schwarz D, Schröder A. Dimensions of coping in chronic pain patients: factor analysis and cross-validation of the German version of the Coping Strategies Questionnaire (CSQ-D). Rehabil Psychol. 2013 Nov;58(4):386-395. doi: 10.1037/a0034358. 34. Phelan C. An innovative approach to targeting pain in older people in the acute care setting. Contemp Nurse. 2010 Jun;35(2):221-233. doi: 10.5172/conu.2010.35.2.221. 35. Naveh P, Leshem R, Dror YF, Musgrave CF. Pain severity, satisfaction with pain management, and patient-related barriers to pain management in patients with cancer in Israel. Oncol Nurs Forum. 2011 Jul;38(4):E305-E313. doi: 10.1188/11.ONF.E305-E313. 36. Dezutter J, Wachholtz A, Corveleyn J. Prayer and pain: the mediating role of positive re-appraisal. J Behav Med. 2011 Dec;34(6):542-549. doi: 10.1007/s10865-011-9348-2. 37. Thompson A, Wilson M, James T, Symbal J, Izumi S. Feasibility study to implement nurse-delivered massage for pain management. J Hosp Palliat Nurs. 2013 Oct;15(7):403-409. doi: 10.1097/NJH.0b013e31829e0ed2. 38. Vaajoki A, Kankkunen P, Pietilä A, Kokki H, Vehviläinen-Julkunen K. The impact of listening to music on analgesic use and length of hospital stay while recovering from laparotomy. Gastroenterol Nurs. 2012 Jul-Aug;35(4):279-284. doi: 10.1097/SGA.0b013e3182608fc1. 39. Wang HL, Keck JF. Foot and hand massage as an intervention for postoperative pain. Pain Manag Nurs. 2004 Jun;5(2):59-65. 40. Potter C, Dunton N, Beck S. Pain care quality and RN staffing characteristics among United States adult medical, surgical units. J Pain. 2013 Apr;14(4):S39. doi: 10.1016/j.jpain.2013.01.454. 41. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011 Apr;32(4):305-314. doi: 10.1086/658938. 42. Bird D, Zambuto A, O’Donnell C, et al. Adherence to ventilator-associated pneumonia bundle incidence of ventilator-associated pneumonia in the surgical intensive care unit. Arch Surg. 2010 May;145(5):465-470. doi: 10.1001/archsurg.2010.69. 43. Paul R, Melendez E, Stack A, Caprano A, Monuteaux M, Neuman MI. Improving adherence to PALS septic shock guidelines. Pediatrics. 2014 May;133(5):e1358-e1366. doi: 10.1542/peds.2013-3871. 44. van Zanten AR, Brinkman S, Arbous MS, Abu-Hanna A, Levy MM, de Keizer NF; Netherlands Patient Safety Agency Sepsis Expert Group. Guideline bundles adherence and mortality in severe sepsis and septic shock. Crit Care Med. 2014 Aug;42(8):1890-1898. doi: 10.1097/CCM.0000000000000297. 45. Beck SL, Towsley GL, Berry PH, Brant JM, Smith EM. Measuring the quality of care related to pain management: a multiple-method approach to instrument development. Nurs Res. 2010 Mar-Apr;59(2):85-92. doi: 10.1097/NNR.0b013e3181d1a732. 46. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994 Mar;23(2):129-138. 47. Pett MA, Beck SL, Guo JW, et al. Confirmatory factor analysis of the pain care quality surveys (PainCQ©). Health Serv Res. 2013 Jun;48(3):1018-1038. doi: 10.1111/1475-6773.12014. 48. Hamlin AS, Robertson TM. Pain and complementary therapies. Crit Care Nurs Clin North Am. 2017 Dec;29(4):449-460. doi: 10.1016/j.cnc.2017.08.005. 49. Lakhan SE, Sheafer H, Tepper D. The effectiveness of aromatherapy in reducing pain: a systematic review and meta-analysis. Pain Res Treat. 2016;2016:8158693. doi: 10.1155/2016/8158693. 50. Boonstra AM, Stewart RE, Köke AJ, et al. Cut-off points for mild, moderate, and severe pain on the numeric rating scale for pain in patients with chronic musculoskeletal pain: variability and influence of sex and catastrophizing. Front Psychol. 2016 Sep 30;7:1466. doi: 10.3389/fpsyg.2016.01466. 51. Gerbershagen HJ, Rothaug J, Kalkman CJ, Meissner W. Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods. Br J Anaesth. 2011 Oct;107(4):619-626. doi: 10.1093/bja/aer195. 52. Jensen MP, Castarlenas E, Tomé-Pires C, de la Vega R, Sánchez-Rodríguez E, Miró J. The number of ratings needed for valid pain assessment in clinical trials: replication and extension. Pain Med. 2015 Sep;16(9):1764-1772. doi: 10.1111/pme.12823. 53. Jensen MP, Mardekian J, Lakshminarayanan M, Boye ME. Validity of 24-h recall ratings of pain severity: biasing effects of “peak”and “end”pain. Pain. 2008 Jul 15;137(2):422-427. doi: 10.1016/j.pain.2007.10.006. 54. Bolton JE, Humphreys BK, van Hedel HJ. Validity of weekly recall ratings of average pain intensity in neck pain patients. J Manipulative Physiol Ther. 2010 Oct;33(8):612-617. doi: 10.1016/j.jmpt.2010.08.009. 55. Mitchell MD, Lavenberg JG, Trotta RL, Umscheid CA. Hourly rounding to improve nursing responsiveness: a systematic review. J Nurs Adm. 2014 Sep;44(9):462-472. doi: 10.1097/NNA.0000000000000101. 56. Daniels JF. Purposeful and timely nursing rounds: a best practice implementation project. JBI Database System Rev Implement Rep. 2016 Jan;14(1):248-267. doi: 10.11124/jbisrir-2016-2537. 57. Buckenmaier CC 3rd, Galloway KT, Polomano RC, McDuffie M, Kwon N, Gallagher RM. Preliminary validation of the defense and veterans pain rating scale (DVPRS) in a military population. Pain Med. 2013 Jan;14(1):110-123. doi: 10.1111/j.1526-4637.2012.01516.x. 58. Lough ME, Rice KL. Transferring scientific knowledge into action at the point of care: do we have all the facts? Clin Nurs Spec. 2016 Nov/Dec;30(6):315-317. doi: 10.1097/NUR.0000000000000249. 59. Shelton RC, Cooper BR, Stirman SW. The sustainability of evidence-based interventions and practices in public health and health care. Annu Rev Public Health. 2018 Apr 1;39:55-76. doi: 10.1146/annurev-publhealth-040617-014731. 60. Tavernier SS, Guo JW, Eaton J, Brant JM, Berry P, Beck SL. Context matters for nurses leading pain improvement in U.S. hospitals. Pain Manag Nurs. 2018 Oct;19(5):474-486. doi: 10.1016/j.pmn.2018.05.003. 61. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional 94 Ochsner Journal Rice, KL Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016 Feb;17(2):131-157. doi: 10.1016/j.jpain.2015.12.008. 62. Beck SL, Dunton N, Berry PH, et al. Dissemination and implementation of patient-centered indicators of pain care quality and outcomes. Med Care. 2019 Feb;57(2):159-166. doi: 10.1097/MLR.0000000000001042. This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care, Medical Knowledge, and Practice-Based Learning and Improvement. Volume 19, Number 2, Summer 2019 95