Sally Nissen, lead nurse palliative care [email protected]
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Transcript of Sally Nissen, lead nurse palliative care [email protected]
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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 [email protected]
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• Improving pain management in children with complex disabilities
• National guidance • Local agreed standards• Audit tool (methodology)• Supportive interventions for
changing practice• Audit results
Overview
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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
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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)
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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
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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
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Local agreed standards
• All children will have pain tool identified• All pains addressed by an intervention • All interventions evaluated
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Why audit?• To evaluate whether standards are being met• Pain identified as a gap in measured outcomes
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Methodology• Review of nursing care files• Eight departments audited • Retrospective review of seven
days
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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
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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
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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%)
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Evidence based guideline
• Local context applied to national guidance• Pain tools and a decision tree• Interventions • Coordinated approach
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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
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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
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• 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
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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)
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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
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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
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2010 2011 20120%
20%
40%
60%
80%
100%
22.7% (n=5)
62.5% (n=20)69.8% (n=58)
% Interventions evaluated
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2010 2011 20120%
20%
40%
60%
80%
100%
4.3% (n=1)
19.4%(n=6) 11.3%
(n=6)
% Children prescribed regular analgesia
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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%
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Conclusion
• > 10% improvement on most aspects• Change in practice is slow• Pain management has been improved• Continued improvement is needed
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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
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Thank you for listening