Improving pain management in children and young people with complex disabilities, resulting from acquired brain injury and neurological conditions, at a residential
facility
Sally Nissen, lead nurse palliative [email protected]
• Improving pain management in children with complex disabilities
• National guidance • Local agreed standards• Audit tool (methodology)• Supportive interventions for
changing practice• Audit results
Overview
The Iowa model of evidence based practice to promote quality care (Titler, et al. 2001)
• Pain - a priority for the organisation?• Trigger• Research and related literature • Design EBCPG, implement and evaluate • Monitor/analyse • Disseminate results
Pain in children with complex disabilities (acquired brain injury and neurological conditions)
• Pain may not recognised (Hunt et al, 2003)
• Higher risk due to health conditions, investigative procedures and treatments (Breau, 2003)
• Higher risk of accidental and non accidental injuries (Breau, 2003)
• Less likely to receive active pain management (Stallard et al, 2001)
Current national guidanceRoyal College of Nursing (2000; 2009)
• Health professionals should anticipate pain in children at all times
• A validated pain tool should be used • Assess pain at regular intervals
Royal College of Anaesthetists and Pain Society (2003)
• Pain and its relief must be assessed and documented on a regular basis
National Service Framework: Children and Young People who are ill (2007)
• Pain management is routine• Regular audit of children's pain management
• Particular attention to children who cannot express their pain because of their level of speech, understanding, communication difficulties, or their illness or disability
Local agreed standards
• All children will have pain tool identified• All pains addressed by an intervention • All interventions evaluated
Why audit?• To evaluate whether standards are being met• Pain identified as a gap in measured outcomes
Methodology• Review of nursing care files• Eight departments audited • Retrospective review of seven
days
Methodology continued
• Evidence of pain tools• Evidence of words indicating possible pain,
discomfort or distress. e.g. ‘crying'; 'sore.’• Evidence of pain tools used• Interventions• Interventions evaluated• Regular analgesia
Pain indicator Evidence of pain tool used
Intervention Intervention evaluated
Crying, grimacing, legs, tense, legs drawn up, difficult to console
pain score 8 (using FLACC revised)
Comforted by mum, moved from chair to lying down, paracetamol given
Settled and slept; pain score 0 within 30 mins
Example of documentation
Audit results 20102010
Pain tool in child’s file 2/23 (8.7%)
Pain tool used during audit period 0%
Pain indicators 41
Pains addressed by an intervention 22/41 (53.7%)
Interventions evaluated 5/22 (22.7%)
Regular analgesia 1/23 (4.3%)
Evidence based guideline
• Local context applied to national guidance• Pain tools and a decision tree• Interventions • Coordinated approach
When communication of ‘Yes’ or ‘No’
is easy
Sufficient Cognitive Ability(and > 4 years)
Some Cognitive Impairment
( and > 3 years)
Direct Questioning: Numeric Rating Scale
(McCaffery and Beebe, 1993)
Wong/Baker Faces Scale (Wong et al, 2001)
If in
doubt Therapy assessment advises individually
adapted or simplified tool
If in doubt go to when communication is difficult
When communication of ‘Yes’ or ‘No’
is difficult
FLACC revised (Malviya et al, 2006) Individual pain
assessment profile
Neurologically Impaired or < 3 yrs
NOT known well by staff
Neurologically Impaired or < 3 yrs
known well by staff
Disorder of consciousness
Nociception coma scale(Schnakers et al, 2010)
If consciousness improves
review tool
• Educational materials • Conferences/lectures/workshops• Local consensus process• Educational outreach visits• Local opinion leaders• Patient mediated interventions• Audit and feedback• Reminders (manual or computerised)• Marketing
(Grimshaw J, Shirran L, Thomas R et al. 2001)
• Interventions offer a median effect of 10% improvement (Grimshaw, Eccles and Tetroe, 2004)
Changing practice
Pain indicators per child/week
2010 2011 20120
0.5
1
1.5
2
2.5
3
1.7 (n=23) 1.5
(n=31)
2.4 (n=54)
2010 2011 20120%
20%
40%
60%
80%
100%
8.7% (n=2)
54.8% (n=17)
64.8% (n=35)
0.0%2.0% (n=1)
14.8% (n=19)
% Children’s files with pain tool % Pain tools used when pain indicated
2010 2011 20120%
20%
40%
60%
80%
100%
53.7% (n=22)
66.7% (n=32)62.5% (n=83)
% Pains addressed by an intervention
2010 2011 20120%
20%
40%
60%
80%
100%
22.7% (n=5)
62.5% (n=20)69.8% (n=58)
% Interventions evaluated
2010 2011 20120%
20%
40%
60%
80%
100%
4.3% (n=1)
19.4%(n=6) 11.3%
(n=6)
% Children prescribed regular analgesia
Summary of all resultsDifference 2010 - 2012
Pain tool in child’s file Total ↑56.1%
Pain tool used for pain Total ↑14.8%
Pains addressed by an intervention Total ↑8.8%
Interventions evaluated Total ↑47.1%
Regular analgesia Total ↑7%
Conclusion
• > 10% improvement on most aspects• Change in practice is slow• Pain management has been improved• Continued improvement is needed
A big push forward…
1. Continue interventions to change practice2. Individual team efforts 3. Managers review pain scores 4. Continue special interest group 5. Move to adopt EBPCG as policy
Thank you for listening
