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 care
[email protected]
Overview
• Improving pain management in children with
complex disabilities
• National guidance
• Local agreed standards
• Audit tool (methodology)
• Supportive interventions for
changing practice
• Audit results
The Iowa model of evidence based practice
to promote quality care (Titler, et al. 2001)
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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 guidance
Royal 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
Example of documentation
Pain indicator
Evidence of
pain tool used
Crying,
pain score 8
grimacing, legs, (using FLACC
tense, legs
revised)
drawn up,
difficult to
console
Intervention
Intervention
evaluated
Comforted by
mum, moved
from chair to
lying down,
paracetamol
given
Settled and
slept; pain
score 0 within
30 mins
Audit results 2010
2010
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
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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)
Direct Questioning:
Numeric Rating Scale
(McCaffery and Beebe, 1993)
Some Cognitive
Impairment
( and > 3 years)
Wong/Baker Faces Scale
(Wong et al, 2001)
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
Neurologically Impaired
or < 3 yrs
NOT known well by staff
FLACC revised (Malviya
et al, 2006)
Neurologically Impaired
or < 3 yrs
known well by staff
Individual pain
assessment profile
Disorder of
consciousness
Nociception coma scale
(Schnakers et al, 2010)
If consciousness
improves
review tool
Changing practice
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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)
Pain indicators per child/week
Summary of all results
Difference
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
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> 10% improvement on most aspects
Change in practice is slow
Pain management has been improved
Continued improvement is needed
A big push forward…
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Continue interventions to change practice
Individual team efforts
Managers review pain scores
Continue special interest group
Move to adopt EBPCG as policy
Thank you for listening