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Page 2
DEVELOPMENT
OF PEDIATRIC PAIN Development of an Inpatient Pain Management Program In developing a model for the inpatient setting, we first established a Pain Management Committee to design the program's policy and procedures, and Pain Management Teams to carry out these procedures. Moreover, the Pain Management Committee was assigned to meet monthly to discuss emerging issues regarding the program. Following a comprehensive literature review, pain assessment tools were selected, and a pain assessment protocol was developed. We selected the CRIES Scale, FACES Scale, and Oucher Scale. Our protocol for pain assessment begins with an initial assessment of the patient's pain on admission using the pain assessment form. If the patient has no pain on this initial assessment, the nurses caring for the patient then continue to routinely assess the patient's pain using the appropriate pain scale (i.e. CRIES, FACES, Oucher) during their hospital stay. If the patient has pain either o the initial assessment or during their hospital stay, they are then referred to the Mental Health Specialist for a comprehensive pain evaluation using the Varney/Thompson Pediatric Pain Questionnaire. If the patient is evaluated as having physical pain, the Pain Management Team intervenes and provides continuous treatment assessment of the pain. If the pain resolves, the patient is again assessed routinely by the nurses using the appropriate pain scale (i.e. CRIES, FACES, Oucher). In addition, contact with information exchanges such as the PainLink project and several pediatric pain management specialists were initiated. This increased focus on liaisons with other pain management programs was for the purpose of sharing information, discussion of pertinent issues, and exploring possibilities for collaborative efforts. These affiliations continue to increase as our program expands. Policies and procedures developed by the Pain Management Committee also included adjuvant pain management modalities such as acupuncture, acupressure, hypnosis, imagery, and biofeedback. Additional policies were developed for the use of patient controlled analgesia and EMLA cream. Other modalities were researched and implemented. EEG biofeedback training with a psychologist was employed for the reduction of pain-related anxiety and distress. Controlled studies on magnets were collected to provide additional techniques to current practice. Training was then provided to caregivers by the Pain Management Team in the administration of appropriate pain management treatments. These sessions included medical and nursing staff inservices on the use of patient controlled analgesia, the appropriate uses of the pain assessment tools, and on the overall protocols for pain management. To provide continuous pain management training, a process was developed based on participation learning. Clinical bedside rounds were also developed to assist in the implementation of pain management techniques and for the continuing education of staff in appropriate uses of assessment tools and protocols. Overseen by the Pain Management Team, these rounds created a uniform pain management approach that was incorporated into regular patient care meetings. Staff members would report on a patient's pain at these regular patient care meetings and would receive feedback from the Pain Management Team. This collaboration created a supportive environment, in which patient care was enhanced while maintaining the relationship between the patient and the staff members involved in direct care. External educational efforts were also made, such as providing inservicing in pain management procedures at a referring hospital. For the staff, parents, and visitors of St. Mary's community, a presentation of specialized material was given during Pain Management Week at both St. Mary's Hospital for Children and St. Mary's Rehabilitation Center for Children. This presentation included an informational poster presentation and take-home materials. To maximize treatment efficiency, we analyzed pain etiology in our patient population and discovered that major causes included post-surgery pain in orthopedic patients, chronic immune deficiency, low back pain, spasicity, cancer, and joint immobility. Occasionally, controversial treatment options were present with particular types of pain. For example, with severe abdominal pain, hot packs were found to be an effective means to soothe the patient but caused significant skin irritation. Opiates, on the other hand, while effective in relieving pain without causing skin irritation, further decreased gut motility. The Pain Management Team helped to address these and other similar issues. The Quality Assurance component of the Pain Management Program included monitoring of compliance through chart reviews in the program as well as a random sample of patients not currently enrolled in the program. As with any program initiation, compliance with pain assessment was initially difficult. However this gradually improved with continuous education by the Pain Management Team during the clinical bedside rounds. Staff compliance with routine pain assessment was problematic not only in our institution but also in all of the other institutions we either visited or communicated with. We minimized this problem with compliance by simplifying the documentation of pain assessment. In additional, we found that continuous work in educating all staff regarding pain management and taking measures (e.g. chart audits) to improve adherence to established standards was necessary to maintain a high level of compliance. Development of a Home Care Pain Management Program The second step in the implementation of the pain management program was to adapt the inpatient model for use in the pediatric home care setting. A home care team was formed, led by the Assistant Director of St. Mary's Home Care Program, to initiate and monitor the development of home care pain management protocols, policies and procedures. We determined that the home care phase of the program was not merely an extension of the inpatient program, but required a completely unique set of policies and protocols for development and implementation. This is due to the much larger number of caregivers involved who require training, the wide variety of patient needs, and the lack of twenty-four hours a day staff availability that is present in the inpatient setting. Therefore, initial input was solicited from home care providers to tailor the pain assessment tool to incorporate the needs of patients in the Home Care Program. The Home Care team then developed a strategy to assess pain in home care patients and work with physicians to provide appropriate interventions for pain management. Inpatient pain management policies were revised so they better conformed to the unique needs of the home care setting. The major challenges addressed included determining who should be notified when pain is identified in a home care patient, who should be responsible for developing the pain management plan, and how our home care nurses should provide evaluation and follow-up. We then determined criteria for the use of the pain assessment tool in a variety of situations, such as post operatively, during use of patient controlled analgesics, and post-trauma. This initiated a redevelopment of the process flow sheet in order to indicate when pain assessment should take place as well as the protocols to follow after the analysis of the information obtained from the assessment. Given to home care nurses, this flow chart provided concrete assistance in learning the pain management program and implementing the assessment process. Overall, the goal was to make the home care system consistent but flexible enough to be adaptable to multiple home care needs. The Home Care program selected an assessment form and also used the RIES Scale, FACES Pain Rating Scale, and OUCHER Scale for the evaluation of pain. Following a two-month pilot period, the following procedures were adopted:
If three interventions fail to relieve pain, the home care nurse confers with his/her supervisor and the patient's primary care physician for assistance.
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