Pain: Intervention Bundle

Pain Intervention Bundle Icon

Pain is the number one reason for seeking care in the Emergency Department [1,2,3]. A patient and family-centered approach that includes attention to pain and distress has been tied to improved patient experience while facilitating successful procedure and diagnostic testing completion in the emergency department (ED) [4]. Pain is subsequently less managed in younger children in the ED [5,6].

Despite significant advances over the decades, pediatric pain assessment and subsequent management remain a great challenge in the ED setting. This challenge can be attributed to the difficulty distinguishing between anxiety and pain in children, unfamiliarity with new products and techniques, fear of medication adverse effects, lack of comfort and familiarity with pediatric dosing, as well as staffing and time constraints required to administer medications to children [7]. With appropriate pain assessment, newer analgesic agents and delivery methods such as topic anesthetic agents, distraction and non-pharmacological interventions can be applied earlier in the presentation and even at triage. These techniques are making pediatric pain management easier than ever.

This intervention bundle is designed to help guide PRQC teams that strive to implement change strategies specific to the clinical care process for children who present to the ED with pain. Teams can select to work on an intervention specific to pain for their quality improvement project.

It is anticipated that individual hospital/facility teams will choose one or more NPRQI quality measures to work on. The following measures are included within the National Pediatric Readiness Quality Initiative (NPRQI), where you will enter select data. Please see here to learn more about the quality measure development.

The quality measures related to pain are:

Assessment

  • Percentage of pediatric patients with pain assessed

Gathering data when implementing changes to your system is important. Data collection allows you to measure how the implementation is going and if the changes are moving towards the process measure goal.  Data and measurement can help you give insight on how the changes are being accepted or not accepted into your system.


There are a variety of ways to assess how your implementation is going.  Some include:

  • Chart audits to evaluate the process measure. Considerations include:
    • Timing: Conducted in real-time or retrospectively, and can be automatically set up in a report to capture the pain assessment field from the flowsheet when possible
    • Sampling: All charts or a representative sample of charts selected for surveillance using a random or systematic sampling approach (e.g., every 5th pediatric patient over 10 years old, random number generator of x charts in a sample or all pediatric patients evaluated over a given time period).
  • Staff survey. Considerations include feedback on:
    • Compliance
    • Comfort with pain scores
    • Knowledge of pediatric pain treatment options
    • Experience and satisfaction with the implementation
  • Parent/Patient/Caregiver survey

Below you will find suggested possible interventions, also called change strategies, for the process measure. These are suggestions on different steps that may assist your team in accomplishing the aim you are focusing on. Interventions or change strategies are often grouped into “Guidelines/Protocols, Education, Electronic Medical Records Optimization, and Resources (inclusive of personnel and equipment)”.

As the local expert, you may have other ideas regarding how to best implement change in your hospital or ED. You should always feel free to reach out to your team leader and/or brainstorm these ideas with the other ED team leaders or participants working on similar aims in this collaborative.


Quality Measure: Percentage of Pediatric Patients with Pain Assessed


WRITTEN POLICY/PROCEDURE

Change Strategies

  • Adopt validated pain scales for the correct age groups
  • Conduct pain assessment at triage or with initial vitals
  • Establish a triage pain protocol for addressing pain scores
  • Written procedure/guideline should include pain assessment norms for children
  • Select and define threshold pain level for treatment at your site (for example, pain score > 8 indicates severe pain and should be treated immediately)
  • Identify timeframe/frequency of pain re-assessment (for example, pain reassessment should occur 30 minutes after IV/IN medication administration, 60 minutes after oral medication)
  • Ongoing monitoring and data collection through chart reviews to track adherence to guideline recommendations


NOTIFICATION PROTOCOL

Change Strategies

  • Establish criteria for activating the notification protocol
  • Consider using a designation on ED tracking board
  • Establish a communication method to make the care team aware of the need for pain management and reassessment
  • Key areas of focus: Which members of the care team should be contacted, Method of contact, Frequency of re-assessments
  • Develop a recommended course of action when pain is present, such as a written guideline pathway, or protocol
  • Implement standing physician orders in triage if allowable


EMR OPTIMIZATION

Change Strategies

  • EMR alerts when a pain score is moderate or severe
  • EMR alerts for pain reassessment at a certain time interval, and/or with discharge vitals
  • Integrate a clinical decision support tool or pain medication order set


EDUCATION

Change Strategies

  • Develop a training/educational program for the care team.
  • Learning objectives should include:
    • Importance of pediatric pain management
    • Management options
    • Pediatric pain assessment tool use
  • Identify training delivery modality (e.g., online, in-person staff meetings, peer-to-peer, tabletop exercises, simulation) consistent with other successful training modalities in your ED
  • Identify training frequency


KNOWLEDGE REINFORCEMENT FOR CARE TEAM

Change Strategies

  • Reminders during shift change huddles
  • Posters in triage and exam rooms with child-appropriate pain scales
  • Pocket cards/badge cards for care team with medication dosing ranges
  • Direct feedback to care team following chart audits

Q: When ideally is the best time to assess pain in the pediatric population?

A: At the time, you can most consistently assess the patient and document it; for many, this will first be in triage, as it will provide the maximum time to address pain if identified. After identifying this time and place for your organization, standardize the operational procedures so every patient has the opportunity to be assessed with every encounter.


Q: When doing pain reassessment, do you rely solely on the number scale or do you consider the patient's reaction, such as lying comfortably in the room with parents?

A: When reassessing pain, consider a combination of the two. It is important to note that research and data regarding patients with chronic pain have identified the importance of applying both a reported pain score and appearance. For patients with chronic pain the way they look and act may not be indicative of how severe their pain is, as they may be employing mitigation practices to decrease their pain. It's recommended that you utilize the pain scale based on age approved in your ED, so that a consistent assessment and reassessment can be recorded of the patient's pain. Self-report, if able, is the most reliable measure. Thus, an initial assessment is not solely based on how the child is acting or what they are doing in the room. To understand how an intervention has affected pain, use the same scale to reassess pain.

When patients are applying coping strategies to help mitigate pain, their appearance may not be indicative of the pain they are experiencing. There are no vital sign changes or lab markers to easily confirm level of pain. We may hear the comment, “They are 10/10 but they are on their phone”. It is important that we still consider the patient's verbal report of pain.


Q: How best to approach the current practice of under-dosing or avoiding pain management for pediatric patients, specifically very young patients, to improve practice?

A: The first step is pain assessment. Having your team understand, no matter how old or how verbal, that pain assessment in children is important. Applying developmentally appropriate pain assessment scales is the next step and will help illustrate that pediatric patients have pain and methods to quantify it. Reference PEAK: Pain for resources on pediatric dosing.


If you have any additional questions, please email collaboratives@emscimprovement.center

Resources

Recommended Pain Scales in Children

  1. FLACC-R Score- for children 0-3 years of age or non-verbal https://media.starship.org.nz/rflacc/rflacc.pdf
  2. Faces Pain Scale-Revised- For children 4-12 years of age https://www.iasp-pain.org/resources/faces-pain-scale-revised/
  3. Verbal Numerical Rating Score- For children over 6 years of age chrome- https://www.seattlechildrens.org/pdf/PE952.pdf
  4. Stoplight Pain Scale https://stoplightpainscale.com/

EIIC Pediatric Education and Advocacy Kit (PEAK): Pain

https://emscimprovement.center/education-and-resources/peak/peak-pediatric-pain/


References

1.Danseco ER, Miller TR, Spicer RS. Incidence and costs of 1987–1994 childhood injuries: demographic breakdowns. Pediatrics.2000;105(2):E27.2.

2.Spady DW, Saunders DL, Schopflocher DP, et al. Patterns of injury in children: a population-based approach.Pediatrics.2004;113(3Pt1):522-529.3.

3.Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI)multi-center study.JPain.2007;8(6):460-466

4.Kennedy RM, Luhmann J, Zempsky WT. Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics.2008;122(3):S130-3

5.Gates M, Hartling L, Shulhan-Kilroy J, MacGregor T, Guitard S, Wingert A, Featherstone R, Vandermeer B, Poonai N, Kircher J, Perry S, Graham TAD, Scott SD, Ali S. Digital Technology Distraction for Acute Pain in Children: A Meta-analysis. Pediatrics. 2020 Feb;145(2):e20191139. doi: 10.1542/peds.2019-1139. Epub 2020 Jan 22. PMID: 31969473.

6.Eijlers R, Utens EMWJ, Staals LM, de Nijs PFA, Berghmans JM, Wijnen RMH, Hillegers MHJ, Dierckx B, Legerstee JS. Systematic Review and Meta-analysis of Virtual Reality in Pediatrics: Effects on Pain and Anxiety. Anesth Analg. 2019 Nov;129(5):1344-1353. doi: 10.1213/ANE.0000000000004165. PMID: 31136330; PMCID: PMC6791566.

7.Fein JA, Zempsky WT, Cravero JP. Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems. Pediatr November 2012, 130 (5) e1391-e1405; DOI: https://doi.org/10.1542/peds.2012-2536