MOPAT
A new tool for assessing pain in
hospice patients who can’t self-report
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 Tool
 University of Maryland School of Nursing
 Preliminary work (McGuire & Reifsnyder, 2004)
suggested that at least 2 dimensions of acute pain—
behavioral and physiologic—could be assessed in noncommunicative 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 non-communicative 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
Behavioral Subscale
Behavioral Pain Indicators
0 (None or Normal)
1 (Mild)
2 (Moderate)
3 (Severe)
Restless
Quiet
Slightly restless (fidgety)
Moderately restless
(tossing/turning)
Very restless (agitated, constant
movement)
Tense Muscles
Relaxed
Slight tenseness (Guarding)
Moderate tenseness (sensitivity or
mild resistance to movement)
Extreme tenseness (stiffness or
total body rigidity)
No frowning or grimacing
Slight frowning or grimacing
(furrowed brow)
Moderate frowning or grimacing
Constant frowning or grimacing
Quiet
Sighs, groans, moans softly
Groans, moans loudly
Cries out or sobs
(Muscle Tension)
Frowning/Grimacing
(Facial Expression)
Patient Sounds (Vocalization)
S
(Record ‘4’ if unable to vocalize)
Behavioral Score
Physiological Subscale
Physiological Pain Indicators
0 (Usual or No Change from Usual)
1 (Not Usual or Change from Usual)
Heart Rate
Usual/No Change
Change from usual
Respirations
Usual/No Change
Change from usual
Diaphoresis
Usual/Absent
Present
S
Physiological Score
TOTAL SCORE
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
100
80
60
40
20
0
M
ar
t
p
Se
M
ar
t
p
Se
Results: Return Rate CUQ’s (%)
100
80
60
40
20
ep
t
S
ar
M
ep
t
S
M
ar
0
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
1. MOPAT took a reasonable amount of time to complete.
2. MOPAT was easy to use.
3. MOPAT would be feasible for regular use in my clinical setting.
4. MOPAT was easy for me to understand.
5. MOPAT guided me in what to look for when assessing pain.
6. MOPAT assisted me in communicating to others about a
patient’s pain.
7. MOPAT was helpful in determining the presence of pain in a
non-communicative patient.
8. MOPAT was helpful in determining whether a patient might
need a pain intervention.
9. MOPAT could be used by informal caregivers (family, friends)
with some training.
Strongly
Disagree
Disagree
Undecided
Agree
Strongly
Agree
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
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
 Didn’t 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 report—if 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
 Don’t 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 CUQ’s 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