DEVELOPMENT OF PEDIATRIC PAIN
MANAGEMENT PROGRAMS IN POST-ACUTE REHABILITATION SETTINGS

Challenges

In developing a pediatric pain management program for children in post-acute inpatient rehabilitation and home care settings, there have been challenges. One was not being able to visit other post-acute rehabilitation settings with pain management programs due to the dearth of post-acute facilities with pain management. Most of the facilities with pain management programs we communicated with and visited were in acute pediatric care settings and therefore not directly comparable. Another difficulty was in the education of all staff members in the hospital community. An attempt was made to include all workers who may encounter patients complaining of pain. However, since the attendance in inservices was less than we had hoped, we feel that we need to make a more concerted effort to educate this population through alternative means (e.g. training videotapes). Additionally, although complementary medicine is widely used, we discovered that legal issues, such as an appropriate consent protocol, are not well established. Therefore, we had to address these legal issues prior to incorporating them in our pain management program. Lastly, our evaluation system was initially not as effective as it could have been. Since our evaluation process was incorporated during the implementation process, there was no baseline evaluations available, making progress difficult to determine. We are fortunate, however, that these areas of difficulty are amendable, and we plan to resolve them in our plans for the future.

Steps in Implementing a System-Wide Pain Management Program

Overall, implementation of the Pain Management Program at St. Mary's Healthcare System for Children involved several necessary steps:

• Development of a blueprint to provide an overview of implementation.
• Development of a pain management committee to develop protocols of selected pain management modalities that include not only traditional tools, such as pharmacology, but also tools from complementary medicine, such as imagery, biofeedback, hypnosis, acupressure, and acupuncture.
• Development of a pain management team to implement the program and serve as a resource for the training and supervision of staff delivering care.
• Comprehensive literature search on effective pediatric pain assessment tools, development of a list of effective pediatric pain management tools, and selection of staff members who will be trained to use them.
• Development of an inservice training program for nurses, child care technicians, therapists, and other staff responsible for the direct care of inpatient children to assess acuity of pain on a regular basis using the selected age-appropriate assessment tools.
• Development of an inservice training program for inpatient caregivers in administering appropriate pain management treatments, in consultation with the appropriate members of the Pain Management Team.
• Implementing the pain management program at both St. Mary's Hospital for Children in Bayside and St. Mary's Rehabilitation Center for Children in Ossining.
• In the home care program, development of appropriate protocols for instituting the pain management program in the home and medical day care settings.
• Development of training programs for staff and caregivers of home care in pain assessment and implementation of pain management techniques in consultation with appropriate members of the pain management team.
• Continuous evaluation of the effectiveness of the entire pain management program, producing both objective and subjective analyses of the effects of pain management on patient comfort, parent satisfaction, and length of stay, and application of any appropriate modifications.

Today, we have successfully developed an effective pain management program for children in both post-acute inpatient rehabilitation and home care settings. We feel that the inpatient program is successfully addressing the pain management needs of children, and the home care pain management program is proving to be effective not only for directing pain management but for increasing awareness of children's pain and the various effective pain reducing modalities as well.

Plans for the Future

In the future, we plan to improve and expand our pain management program. These plans include the following:

• Actively search for other institutions to visit that also have pain management in their home care programs.
• Continue to develop the inpatient as well as the home care component of our pain management program.
• Produce a video about pain assessment to educate hospital staff.
• Continue Q & A evaluations to assess the effectiveness of the pain management program over time.
• Develop a pain research program focusing on specific issues affecting our patient population. For example, one area of research we would like to explore is the assessment of pain in severely neurologically impaired children.

Conclusion

We, at St. Mary's Healthcare System for Children, feel there is a need to focus on both acute and chronic pain in post-acute pediatric settings. More importantly, pediatric pain management programs can and should exist not only in academic medical centers but also in post-acute settings. To be successfully, pain management programs may need to use a combination of pharmacology and adjuvant therapies. These programs provide a more efficient way to help relieve pain in children.

References

Anand KJS, Craig KD: New Perspectives on the Definition of Pain. Pain 1996; 67:3.

Schechter NL, et al: The Ouchless Place: No Pain, Children's Gain. Pediatrics 1997; 99:890-894.

Clancy GT, et al: Neonatal Pain Management. Update on Neonatology 1992; 4(3): 527-535.

Philadelphia College of Pharmacy and Science Management of Pain. 1996; 1(1): 3-26.

Eisenberg DM, et al: Unconventional Medicine in the United States-Prevalence, Costs, and Patterns of Use. The New England Journal of Medicine 1993; 328(4): 246-252.

This article was abstracted with permission from: Development of Pediatric Pain Management Programs In Post-Acute Rehabilitation Settings, a Handbook Developed By St. Mary's Healthcare System for Children, Bayside, New York, edited by Sam S.H. Wu, M.D., M.P.H., Medical Director, Physical Medicine and Rehabilitation. For further information please contact Edwin Simpser, M.D., Executive Vice President and Chief Medical Officer, St. Mary's Healthcare System at Tel. (718) 281-8778, Fax. (718) 281-8590, email: esimpser@stmaryskids.org. Or visit our website at www.stmaryskids.org.

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