MOPAT

A new tool for assessing pain in

hospice patients who cant selfreport
Presenters:
Deborah Bortle, MS, BSN, CHPN
Joan K. Harrold, MD, MPH, FACP, FAAHPM

Pain Assessment in Hospice

Patients
Patients able to self-report
Patients not able to self-report
How do we it?
What are the challenges?
What do we need?

MOPAT: Multidimensional
Objective
Pain
Assessment
University of Maryland School of Nursing
Preliminary work (McGuire & Reifsnyder, 2004)
Tool

suggested that at least 2 dimensions of acute

painbehavioral and physiologiccould be
assessed in non-communicative palliative care
patients.
Goal: to validate the MOPAT and demonstrate
its feasibility in a spectrum of palliative care
settings when used by both nurses and informal
caregivers to assess acute pain in noncommunicative patients.

MOPAT
Hospice of Lancaster County
ADC 450-500
12 bed IPU, mainly GIP
Second IPU opened, 16 beds, mainly GIP
Research MS/BSN 0.5 FTE
On-site IS manager to enable EMR data
collection

MOPAT in Hospice
Remove blood pressure measurements
Not routinely performed, especially at EOL
Could limit future clinical utility
Staff other than nurses
Other caregivers

Study Design
Eligible IPU patients suspected of having pain
Simultaneous MOPAT assessments by Study

RN and Staff nurse (RN or LPN)

1 primary Study RN with 1 back-up

Reassessment following intervention

Timing based on intervention used
Staff MOPAT results documented in EMR
Study MOPAT results not included in patient
record
Serial values were used clinically even if not
recorded for the study

Inclusions/Exclusions
Inclusion
Adults with evidence of pain and not able to

self-report

Exclusions
Non-responsive
Pediatric < 18 years old
RAST < 5
Any diagnosis of dementia

MOPAT

Recruitment and
Education
Hospice decided MOPAT to be used in IPU for
all patients
Regardless of patient enrollment in study
Every IPU nurse trained on MOPAT
MOPAT Incorporated into IPU EMR

UMd created a video of case scenarios

Revised for hospice environment
Unit Director volunteered to be patient in video
Researchers and IPU leaders performed
consensus ratings prior to use for training

Training
Trained staff over 3 months
39 RNs and 22 LPNs agreed to participate in study
1 RN and 1 LPN declined, but still utilized MOPAT
Same instructor for everyone
Out of the IPU for training
Associated color: PURPLE magnets
Included snacks
Thank you gift: MOPAT clipboard
Feedback via fliers when general issues

identified

Clinical Utility
Assessment
Completed monthly by nurses who
volunteered to participate in this arm of study
No additional incentives

Did nurses like the tool?

Would they use the tool?

Patient Enrollment
Project began March 7, 2009
Nurses had 3-5 months to use before
enrollment patient
50 patients enrolled by December 11, 2009
Last patient enrolled November 23, 2010
21 month enrollment period for 100 patients

Challenges to Enrollment
IPU transfers 5pm-8am and on Saturdays
Opening of new IPU 7 miles away
Reasons not enrolled:
50% diagnoses included dementia
22% died prior to study assessment
20% died before re-assessment
2% study nurse not available
2% RAST < 5

Results: Nurses using

MOPAT

Results: Return Rate

CUQs (%)

Results of MOPAT in
Hospice
Reliability
Agreement between Study nurse and Staff

Nurse raters was significant at p<.001, with

moderate-substantial agreement on most
indicators.

Validity
Validity was evidenced by statistically

significant (p<.001) reductions in behavioral,

physiologic, and total MOPAT scores following
pain interventions.

Clinical Utility
Questionnaire

Results: Utility
Guided pain assessment
Assisted in communication
Helped determine if pain

present
Helped determine
intervention needed

63.9%
61.1%
61.6%
60.3%

Results: Ease of Use

Reasonable time to complete
Easy to use
Feasible for regular use
Easy to understand

63.8%
71.5%
57.3%
71.8%

Adjustments to MOPAT
Eliminate diaphoresis on MOPAT tool
Added no value
Shortened time to complete

Home Hospice Roll-out

Roll out to admission team first
Tried to get their feedback before HH roll out
Easier to use than they expected
Liked an objective tool
Didnt like having another form to complete
Recognized need for standardized tool for

patients with dementia who cannot self-report

Dementia in IPU accounted for 50% of those

excluded from MOPAT study

PAINAD added to EMR prior to HH roll-out

Home Hospice Training

Power point presentation in IDT plus make-up

sessions
All IDT members included
Written case scenarios for selection of appropriate

tool
MOPAT and PAINAD tools in handouts

Flow chart on how to document your pain

assessment

Self reportif unable, choose either

PAINAD
MOPAT

Issues in Home Hospice

Nurses using assessment tools interchangeably
Even for same patient
More than expected from fluctuations in clinical status
Using self-report while awake and MOPAT while asleep
Using MOPAT and PAINAD for same patient

Nurses only using a tool after they determine

patient has pain

Need to use to help determine if a patient has pain

Allows next clinician to compare pain levels using

same variables
Communication, not clinical accuracy

Issues in Home Hospice

Definition of dementia
34.8% with dementia had a MOPAT completed
Emphasize self-report first!
What constitutes a diagnosis of dementia?

Problem or dx list? Family report? Clinical notes?

Timing of focus on NQF #0209

Comfort in 48 hours
Self-report only
Diminished focus on assessment of patients
who cannot self-report

Lessons Learned
Roll-out with fanfare
Need excitement to make an impression
Dont roll-out with too many other new things
Use the video scenarios in all training
Ask for feedback
Can use the CUQ, but not every month!

Deliver rapid feedback to teams on MOPAT use

Develop organizational policy regarding

dementia diagnosis

Future Directions
Use CUQs to get nursing feedback in Home

Hospice
Beginning January 2013

Explore use by other caregivers

Nursing home clinicians
Caregivers at home
CUQ: MOPAT could be used by informal caregivers
1.9% disagree
39.8% undecided
58.2% agree

Appreciation to Our
Colleagues
Deborah McGuire, PhD, RN, FAAN
Principal investigator

Karen Kaiser, PhD, RN-BC, AOCN

Karen Soeken, PhD
JoAnne Reifsnyder, PhD, ACHPN