Pain: Intervention Bundle

prqc pain 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 remains 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 should be applied at triage. These techniques are making pediatric pain management easier than ever.

This intervention bundle is designed to help guide PRQC teams that want 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 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 quality measures development.

The quality measures related to pain are:

Pain_ Quality Measure

Gathering data when implementing changes to your system is important. Data collection allows you to measure how your implementation is going and if your changes are moving towards your 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 above
  • Can be conducted in real-time or retrospectively; may be automatically set up in a report to capture pain assessment field from the flowsheet
  • Can be 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, or all pediatric patients evaluated over a given time period).
  • Survey staff on usage and/or comfort with pain scores and treating pediatric pain
  • Consider surveying staff experience and satisfaction with the implementation to better learn from your your intervention strategies
  • Create a brief survey for families for any of the process measures above

Some example numerical metrics you can calculate for each process measure is in the table below:

Pain_ Data Collection

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
  • 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 communication method to make care team aware of need for pain management and reassessment
  • Key areas of focus: Which members of 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 care team when a pain score is moderate or severe
  • EMR alert 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 training/educational program for care team. Learning objectives should include:
  • importance of pediatric pain management, pediatric pain management options; how to assess pediatric pain
  • 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

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

Disclaimer: The views and responses to these FAQ’s are recommendations from the subject matter experts who presented during the Suicide Fireside Chat on July 11, 2023. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government

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 could be in triage. After identifying this time and place within your organization standard operational procedures can be implemented.

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, has 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. It's recommended that you utilize the number scale or modified FLACC based on age or whatever scale your ED chooses to use, so that a tangible and actionable reassessment can be recorded of the patient's pain. An initial assessment is also 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 we should use the same scale to reassess pain.

A: When patients are applying coping strategies to help mitigate pain their appearance may not be indicative of the pain they are experiencing. 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 to change current practice of low-dosing or not providing pain management to pediatric patients, specifically very young patients.

A:First step is assessing the patient's pain. Having your team understand, no matter how old or how verbal they are, pain assessment is important. Applying developmentally appropriate tools to assessing pain is the first 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