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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 care [email protected] Overview.

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sally nissen lead nurse palliative care snissen@thechildrenstrust org uk

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 care

[email protected]

overview
Overview
  • Improving pain management in children with complex disabilities
  • National guidance
  • Local agreed standards
  • Audit tool (methodology)
  • Supportive interventions for

changing practice

  • Audit results
the iowa model of evidence based practice to promote quality care titler et al 2001
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 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 guidance
Current national guidance

Royal 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
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
Local agreed standards
  • All children will have pain tool identified
  • All pains addressed by an intervention
  • All interventions evaluated
why audit
Why audit?
  • To evaluate whether standards are being met
  • Pain identified as a gap in measured outcomes
methodology
Methodology
  • Review of nursing care files
  • Eight departments audited
  • Retrospective review of seven

days

methodology continued
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
evidence based guideline
Evidence based guideline
  • Local context applied to national guidance
  • Pain tools and a decision tree
  • Interventions
  • Coordinated approach
slide14

When communication of

‘Yes’ or ‘No’

is easy

Sufficient Cognitive Ability

(and > 4 years)

Some Cognitive Impairment

( and > 3 years)

If in doubt

Wong/Baker Faces Scale (Wong et al, 2001)

Direct Questioning:

Numeric Rating Scale (McCaffery and Beebe, 1993)

Therapy assessment advises individually

adapted or simplified tool

If in doubt go to when communication is difficult

slide15

When communication of ‘Yes’ or ‘No’

is difficult

Neurologically Impaired

or < 3 yrs

NOT known well by staff

Disorder of consciousness

Neurologically Impaired

or < 3 yrs

known well by staff

FLACC revised (Malviya et al, 2006)

Individual pain assessment profile

Nociception coma scale

(Schnakers et al, 2010)

If consciousness improves

review tool

slide16

Changing practice

  • 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) 
conclusion
Conclusion
  • > 10% improvement on most aspects
  • Change in practice is slow
  • Pain management has been improved
  • Continued improvement is needed
a big push forward
A big push forward…
  • Continue interventions to change practice
  • Individual team efforts
  • Managers review pain scores
  • Continue special interest group
  • Move to adopt EBPCG as policy
ad