DOTS Image

DOTS

Theme: Improving Health & Healthcare

Cohorts 29 & 30 (online)

Project

DOTS

Aim

Overall aim of the project is to improve pain management with people living with dementia.

-  Our SMART aim is a 10% Reduction in numerical score on the Abbey pain scale for People living with dementia within six weeks through the implementation of DOTS.

Description of the Intervention

The cohort identified pain management as a significant challenge for people living with dementia. Evidence presented within the project highlighted that many people with dementia living in UK care homes experience unmanaged pain. Staff reported difficulties recognising pain due to communication barriers associated with cognitive decline, loss of expressive language, and the risk of interpreting pain-related behaviours as behavioural distress rather than indicators of discomfort. This Quality Improvement initiative sought to address these challenges through the introduction of the DOTS approach to pain assessment and management

Who Was Involved

Residents, families, staff

Which MHL tools were used

DOTS

Baseline Position (Before the Project)

Baseline data were collected over a two-week period from five residents. The average Abbey Pain Scale score was 10.2, indicating a moderate level of pain. The project identified several gaps in practice:

  • Pain was not always recognised in people living with dementia.
  • PRN analgesia was not consistently administered when required.
  • Communication difficulties and cognitive decline created barriers to accurate pain assessment.
  • Behavioural symptoms were sometimes misinterpreted as behavioural issues rather than indicators of pain

Changes Implemented

The project introduced the DOTS Framework, a structured approach to pain recognition and management:

D – Do you know the person? Understand the individual's baseline behaviour, communication methods, medical history and previous pain experiences.

O – Observe the person. Monitor for non-verbal indicators of pain such as facial expressions, body language changes, resistance to care, or behavioural changes.

T – Treat the person. Implement appropriate pharmacological and non-pharmacological interventions.

S – So how is the person now? Reassess and evaluate whether interventions have been effective.

The intervention was implemented using a Plan-Do-Study-Act (PDSA) methodology:

  • Collection of baseline data over two weeks.
  • Introduction of the DOTS framework within the care home.
  • Staff training and supervision in both DOTS and the Abbey Pain Scale.
  • Weekly review of pain scores and staff feedback.
  • Consideration of wider rollout if successful

A process map was developed to standardise the assessment and management of pain, supporting staff to consistently identify and respond to potential indicators of discomfort. A driver diagram was also created to identify the key factors influencing effective pain management and to guide implementation activities.

Evidence of Impact / Outcomes

Resident Abbey Pain Scale scores were monitored weekly following implementation of the DOTS framework.

  • Baseline (Weeks 1-2): 10.2
  • Week 3 (DOTS introduced): 10.0
  • Week 4: 9.6
  • Week 5: 10.0
  • Week 6: 8.0

The temporary increase in Week 5 was attributed to staffing pressures and sickness absence, with staff reporting that DOTS had not been consistently applied. Following a refresher session, scores improved further by Week 6. Overall, the project demonstrated a reduction in average pain scores from 10.2 to 8.0 during the six-week period

For Residents

Residents experienced improved pain management, contributing to a better quality of life and a reduction in pain-related distress within the care setting.

For Families

Families reported increased confidence in how pain was being managed and observed more positive interactions with residents during visits. Further evaluation of family experiences was planned as the project progressed

For Staff

Staff became more confident in recognising and managing pain in people living with dementia. The project also suggested the potential for reduced time spent managing distress behaviours, although further study was required to confirm this benefit.

Key Learning

The project team proposed that, if successful, the DOTS framework would be embedded within the current care homes and subsequently rolled out to other services across the organisations.

Sustainability and Spread

A micro eLearning resource created by Dr Deirdre Harkin was used by these participants and is available to  provide ongoing staff education and reinforce the principles of the DOTS framework. This is available on e-learning platform ‘Learn HSCNI’.