Category Archives: Clinical

20 Years of the Integrative Healing Arts Network – Newsletter

by Michele Erich, MM, CCLS, MT-BC and Ann Quinlan-Colwell, PhD, RN-BC, AHNBC, DAAPM

News reports are replete with stories about the problems of opioid use disorder (OUD) and over dose deaths [1,2].  A reasonable approach to addressing this health care crisis is managing pain with a multi-modal approach rather than with opioid mono-therapy.  A multi-modal approach includes a variety of medications including appropriate use of opioids, non-opioid analgesics, co-analgesic agents and non-pharmacologic interventions [3].  Many people may be interested in non-pharmacologic interventions but don’t know much about them, don’t know where to find practitioners or can’t afford them. In addition, they are almost always thought of as interventions for chronic pain and not part of acute care or acute pain management.  One hospital in our region has shown leadership in offering non-pharmacologic interventions in the acute care arena.

This year New Hanover Regional Medical Center, a not for profit community hospital, celebrates the 20th anniversary of their Healing Arts Network (HAN) which has brought non-pharmacologic interventions to patients for the last two decades.  HAN originated as a vision to bring awareness to the use of complementary therapies and to open communication between patients and their physicians in regard to the different complementary therapies patients were considering incorporating into their plans for health and wellness.  The HAN also educated the public about appropriate qualifications of the therapist/practitioners who provide complementary therapies.  After a year or two as part of growth the HAN changed from referring to services as Complementary therapies to Integrative therapies.  The change emphasized the integration of HAN therapies into the medical model of care in both the acute care inpatient setting and outpatient setting.  Physician referrals and assessments are required and primarily address pan management, anxiety, depression, trauma and coping with a new diagnosis/prognosis or change in prognosis of a chronic illness.     

Interventions currently offered by the HAN are expressive therapy, music therapy, child life, massage therapy, therapeutic touch, tai chi/qi gong, yoga, craniosacral therapy and pet therapy.  These services are primarily offered to patients, but during the past year a plan was developed to offer stress relief to the employees of the medical center through chair massage and brief yoga and music therapy relaxation sessions.  Exploration is underway to expand services to further help employees take care of themselves by incorporating Integrative therapies into their own plans for health and wellness.  Expressive Therapy is provided by a Licensed Professional Counselor with a master’s degree in Expressive therapy.  Through Expressive therapy patients can begin to deal with their emotions related to the illness, injury or pain.  She often helps the patients find ways to relax and deal with the stress of their health conditions and hospitalization.  Imagery, breathing techniques, drawing and journaling are all introduced to patients teaching them some coping skills to take home after discharge and use as needed whenever stressed, in pain or anxious.   

Music Therapy is provided by a nationally board-certified therapist with 30 years of experience.  Through music therapy she can find ways to connect with patients who are in crisis, emotional distress or struggling with a diagnosis, treatment or unfamiliar experiences.  The connection between music, therapist and patient provides a safety net allowing the patients to confront their pain, fears or anxiety and begin to cope with their present situation.  Once an adult patient said, “Can you come home with me and play that music so I can relax?”  This patient had participated in breathing exercise with music and imagery to deal with his acute abdominal pain and was able to find relief during the music therapy sessions.  After one music therapy assisted procedural support with a pediatric patient the nurse said, “He actually fell asleep during that procedure.”.  “The music really helped.”    

Child Life offers support to children and families during their hospitalizations and outpatient treatments.  Through the use of music, imagery, art and play Child Life Specialist offer a positive outlet when a child is sick and hospitalized.  They also offer redirection and support during scary or painful procedures using music, breathing techniques, bubbles, Virtual Reality headsets, etc. Massage Therapy is provided by four licensed massage professionals who work on a contractual basis.  They provide full body and partial massages.  The focus is on pain management, relaxation and anxiety reduction and is tailored to the individual’s needs.  The massage is modified to work along with any limitations due to medical conditions, injuries, or medical equipment such as propping a pregnant woman with pillows, or avoiding massage to surgical sites, or modified positioning for a patient on a ventilator with limited mobility.  Partial massages are offered one to two times each week during treatments in the Chemotherapy/Infusion area as well as for patients in the inpatient oncology unit.

Therapeutic Touch (TT) is provided by trained individuals and can be incorporated into standard nursing care by those trained in TT.  Therapeutic touch is not as familiar as some of the other services in the HAN but patients report just as much relaxation and pain management benefits.  TT is a bit of a misnomer since generally the clinician never actually touches the person but rather works in the energy field surrounding the body. For patients dealing with extremely intense pain who can tolerate very little touch or movement It can be  preferred and can often help them to tolerate treatments.  TT has been used with patients from the NICU to palliative care.  Frequently, HAN is consulted by the wound care nurses to use TT to help patients having painful procedures or dressing changes.  Often the patients request TT intermittently between procedures to help with pain control as well.

Tai Chi/Qi Gong is offered by a middle-aged woman who was described by a young man as “that lady is very special; the coolest person I ever met.”  She teaches even patients who are confined to bed the basic techniques of Tai chi.  In addition to the benefit patients derive from Tai Chi in the hospital, they learn a technique that they can continue to use after discharge.  Another young man who lives with a chronic illness reported that he uses the Tai Chi he learned at NHRMC at home.  When he is re-hospitalized, he uses it with the “Relaxation Channel” on the television in his room and looks forward to learning more techniques.

Yoga is taught by two yoga practitioners with over 22 years combined experience and multiple specialty trainings including pregnancy yoga, restorative yoga and gentle yoga.  Sometimes patients who have “always wanted to try yoga” take the opportunity to do so.  Other times people who never thought of yoga, are willing to try it while in the hospital with the time and privacy to do so at no cost to the patient or their insurance.  One professional deep sea fisherman said that he would try anything to ease his pain and later reported that not only did the yoga help but that he would continue to use it to manage his pain.   They usually provide individual sessions but have offered yoga groups for women diagnosed with gynecologic cancers and adults hospitalized with mental health issues.  Both groups have been very well received.

CranioSacral Therapy (CST) uses light touch to release restrictions in the body and create balance.  A special process in CST called somatoemotional release can help relieve the lasting effects of trauma and illness.  A woman receiving treatments for cancer received CranioSacral Therapy and was so profoundly impacted by the reduction in her pain level, stress and tension as well as improved mood and overall well-being that she independently wrote a letter to the CEO of the medical center praising this service and the medical center.  She was also eager to participate in a local television news story to promote the Healing Arts Network and inform other patients of these services and benefits.

Pet therapy is “staffed” by volunteers who bring their specially trained and credentialed dogs.  The dogs must have completed the rigorous pet therapy certification training.   Their owners must go through the NHRMC volunteer training program and commit to bringing their dogs to the medical center at least 30 hours per year.  It is very impressive to observe the response that patients and families have to the special dogs.  One woman later reported that when one of the dogs visited it was the first time she had forgotten her head pain in over 30 years.  Another dog brought a young woman and her mother together sharing an interlude of smiling, giggling and petting the dog just days before the young woman died.

With Music Therapy, Expressive Therapy, Tai Chi/Qi Gong and Yoga patients are introduced to a variety of pain management and relaxation techniques.  Patients can learn the basics, expand upon them and continue to use them to manage pain and cope with challenges of life.  Patients are encouraged to explore resources in the community to further their use of these non-pharmacologic interventions as they strive for health and wellness.

Most recently, HAN joined with the Code Outreach Safety Team (COST) (see SPS issue Winter 2017) working with patients who are hospitalized for six to ten weeks for intravenous antibiotic therapy for serious infections resulting from IV SUD.  A challenge is that due to funding limitations, currently patients can have Tai Chi or yoga or massage once per week and must choose one.  While massage feels good, clinicians encourage the patients to at least try and learn a bit about Tai Chi and yoga because they can continue to use either or both integrative therapies to manage pain and cope with challenges after discharge.  The HAN is currently working with the COST to arrange weekly group yoga and Tai Chi.

The HAN Co-Founder (Michele Erich) not only coordinates the various activities and clinicians but she provides the Music Therapy and Child Life services as well as develops and updates policies and procedures, and complies with the Human Resource department requirements for maintaining all contracts with the HAN contractors.  She worked with the Electronic Medical Record team to create EMR documentation for herself and other HAN providers.  She also coordinates interactions with community groups who offer donations and activities.  Last month she coordinated “Christmas in July” with the local Parrothead fan club, bringing Santa in his sunglasses, summer shorts and Hawaiian shirt to brighten the day of the children hospitalized on the Pediatric unit.  She has also worked for several years with the medical center’s Foundation and Marketing department to receive generous donations of money from the Spirit of Children program, allowing her to furnish the teen side of the Pediatric playroom with an 8-foot high ‘basketball shoot to win game’, a Mustang car pinball machine, a Boom-A-Rang table air hockey game and a Rock-Ola Juke Box.  The most recent project involves the trial of Virtual Reality headsets from AppliedVR to help with pain management, distraction and relaxation during procedures and treatments for pediatric patients and adults receiving cancer treatments.    

To celebrate the 20th anniversary of the Healing Arts Network the clinicians are educating staff and visitors through internal flyers, and public display cases showcasing patient feedback and the services and benefits of the healing arts network.  In addition, there will be open yoga, tai chi/qi gong and music therapy drumming sessions held in the cafeteria courtyard and outside in front of the medical center allowing visitors and staff to participate in some of the services offered through the Healing Arts Network at New Hanover Regional Medical Center.  Certainly 20 years of patients having more fully integrative care as the result of an innovative vision that has been nurtured and has flourished is much to celebrate!

  Reference:

  1. Fleischauer, A. T. (2017). Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence—North Carolina, 2010–2015. MMWR. Morbidity and Mortality Weekly Report, 66.
  2. Rudd, R. A., Aleshire, N., Zibbell, J. E., & Matthew Gladden, R. (2016). Increases in drug and opioid overdose deaths—United States, 2000–2014. American Journal of Transplantation, 16(4), 1323-1327.
  3. Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., … & Griffith, S. (2016). Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. The Journal of Pain, 17(2), 131-157.

Innovation: Opioid Substance Use Disorder

by Ann Quinlan-Colwell, PhD, RN-BC, DAAPM

During 2014, patients were admitted more frequently with diagnoses of soft tissue abscesses, epidural abscesses, and endocarditis. Two common denominators, among many of these patients, were a history of self-administering opioids intravenously and now needing intravenous (IV) antibiotics for prolonged periods of time. This combination posed a challenge for health care providers who believed that it was not prudent or safe to discharge patients with a port or peripherally inserted catheter (PICC) line for IV access when the patient was known to abuse opioids intravenously.  Thus, the patients with these dual diagnoses -serious infections requiring IV antibiotics and substance use disorder- were admitted to the hospital for administration of IV antibiotics for six to twelve weeks. 

Two additional concerns arose. Many providers believed that it was important to control pain and to work with these patients, encouraging them to work toward sobriety.  In many instances this was reasonable and opportune since some of the very ill and scared patients demonstrated greater motivation to seriously consider abstinence and sobriety.  The providers consulted the Pain Management Clinical Nurse Specialists (CNS) to help control the patients’ pain while minimizing opioids and then wean the opioids to discontinuation whenever possible.      

Two cardiovascular surgeons who saw the patients with endocarditis invited a team to meet to address how to best work with the patients with endocarditis resulting from IV substance use (IVSU).  The initial group included the cardiovascular surgeons, infectious disease (ID) physician, cardiology administrator, cardiology nurse administrator, behavioral health administrator, substance abuse counselor, pharmacist, social worker, case manager and pain management CNS.  An addictionologist and community provider of buprenorphine were consulted.

Since patients were also being admitted for non-cardiac infections resulting from IVSU, the team expanded to coordinate with the medical center Code Outreach physicians.  Code Outreach is the established process through which the medical center coordinated interdisciplinary care of patients who were frequently evaluated in the emergency department (ED) and/or admitted.  Eventually, the Code Outreach team assumed primary oversight for interventions, patient care, and group activities. 

The intervention and group is now known as the Code Outreach Special Team or “COST”.  It consists of the two Code Outreach physicians, a pharmacist, the substance abuse counsellors, pain management CNSs, case management, cardiac nurse coordinator and one social worker (MSW). This MSW follows all the patients who are admitted to receive long term IV antibiotics to treat infections resulting from IVSU. Each patient in this category is reviewed weekly by the COST.  At the weekly meetings, the patients’ condition, challenges, pain management, progress toward goals, discharge needs/plans as well as the barriers to achieving these are discussed.  The plan of care is amended as needed. A template was developed for an individualized COST note to be created during the meeting and entered into the electronic medical record for the patient. This COST note is available to all professionals providing care and working with the patient. 

Each of the patients is also individually followed at least weekly by the pain management CNS, substance abuse counsellors and MSW.  The team, especially the MSW, works closely with methadone maintenance programs and providers of buprenorphine in the community to identify resources to connect with the patient prior to discharge.  While hospitalized, the substance abuse counsellors, MSW and pain management CNS work with the patients to encourage and support sobriety.  Recently, the team has located an Alcoholic Anonymous/Narcotics Anonymous group to conduct meetings for this group of patients while hospitalized. 

The pain management CNS works with the patients to control their acute pain which generally requires some opioids as part of a multi-modal analgesic plan of care (MMA-APOC).  As resolution of the acute infection resolves, the focus changes to weaning opioids and progressing to a non-opioid MMA-APOC.  Patients are encouraged to learn non-pharmacologic ways to control pain including square breathing, relaxation, distraction, and exercise.  The medical center Healing Arts Network are consulted for patients to learn tai chi and/or yoga and receive massage. 

Future plans include:

  • the MSW being dedicated full time to working with these patients
  • securing a room for the AA/NA meetings
  • identifying a physician to initiate prescription of buprenorphine for interested patients
  • developing a care plan or care trajectory that provides for consistency with room for individual care
  • educating all medical center staff about the COST, clinical note and care plan
  • increase funding for Healing Arts Network to increase support of non-pharmacologic interventions and education
  • increase interactions with community treatment and behavioral health providers and facilities
  • increase interaction and expand work with families of patients followed by the COST
  • collect and analyze data to determine effectiveness of COST activities
  • obtain grant funding to improve and formalize the COST and increase resources

The dedication and work of the member of the Code Outreach Special Team is acknowledged.

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