OF PEDIATRIC PAIN
MANAGEMENT PROGRAMS IN POST-ACUTE REHABILITATION SETTINGS
of an Inpatient Pain Management Program
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).
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
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.
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.
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.
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.
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.
of a Home Care Pain Management Program
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:
Every patient in St. Mary's Home Care Program receives a baseline
assessment of pain
current pain is addressed, not resolved pain or pain associated
with normal childhood development
All children requiring pain management are assessed for adequacy
of treatment modalities
If three interventions fail to relieve pain, the home care nurse
confers with his/her supervisor and the patient's primary care physician