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 caresnissen@thechildrenstrust.org.uk

• 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