Although the past 10 years have borne witness to a genuine revolution in knowledge about pain in children, in many settings, this information has not necessarily changed practice patterns regarding pain management. In this article, we will describe the program we developed to overcome the impediments to adequate pain management on a pediatric inpatient unit and detail specific goals and objectives, components of the program, and implementation strategies. We believe that this experience has implications for other centers that care for children.
The burgeoning of interest in pediatric pain over the past decade is reflected in the dramatic escalation of research that deals with pain and analgesia in children. When Eland1 reviewed the world's literature on pain in children in 1975, she found only 33 articles, most of which concerned abdominal pain. When Gardiola and Banyos2 did a similar search in 1992, they found 2966 articles published between 1981 and 1990. The new research exploded many of the myths that were thought to constrain appropriate pain management practice such as the belief that young children do not experience pain3 or that the use of potent opioids will lead to addiction.4,5 It demonstrated clearly that even preterm infants experience pain3 and stressed the value of providing adequate comfort to hospitalized children.6 This new information was quickly incorporated into general pediatric textbooks that were previously devoid of information on this subject7 and into continuing medical education programs.
The plethora of new research and exposure to new concepts in pain management has clearly affected the attitudes of many child health care professionals. In older surveys on attitudes, doctors and nurses would often report that they did not perceive that young children experienced pain and felt they had less need for analgesia than adults.8 They would also report concerns about addiction that limited their use of potent analgesics on children with legitimate pain problems. Recent surveys suggest that attitudes have changed significantly about whether or not children feel pain and about the importance of providing adequate comfort.9 These attitudinal shifts parallel some changes in practice and recent surveys10-12 suggest that many aspects of children's pain are treated far more appropriately than in the past when massive undertreatment was the standard of care.13-15
One of the many advances that has emerged over the past decade is the development of children's pain services in many large children's hospitals. The specific responsibilities and configuration of pain services vary depending on local factors and personnel but in general they are responsible for pain control throughout the institution. Because of this clustering of expertise and responsibility, much of the research on pain management has come out of pain services. Relatively low incidence pain problems that ordinarily are scattered among many different services and disciplines are now referred to the pain service where they can be treated and studied. Even in hospitals that have functional pain services however, many patients with pain related problems never come to the formal attention of the service. In addition, pediatric pain services are often not feasible outside of large children's hospitals and as a result, many children are cared for in institutions without them.
Therefore, whether in an institution with a pain service or one without one, despite advances in our understanding of pain and attitudinal change, undertreatment of children's pain remains an issue.10 Systemic and logistical barriers limit the extent to which the concepts of child pain management are translated into the day to day pediatric medical care. The Ouchless Place was designed and implemented to address these barriers.
St Francis Hospital and Medical Center is a large, urban, community-based teaching hospital with a 20 bed pediatric inpatient unit and approximately 1000 pediatric admissions yearly.
During 1995, a multidisciplinary pain interest group composed of representation from pediatrics, surgery, nursing, anesthesia, and pharmacy was formed and met to review the impediments to adequate childhood pain management. The group met over a 6-month period and eventually developed an overall approach to creating as pain-free an inpatient service as was possible. This approach, philosophy, and, in fact, the inpatient unit itself came to be known as The Ouchless Place. The following goals were established for the problems that were identified:
Uniformity of Approaches Regarding Postoperative Pain Management and Sedation.
Although some attending physicians and house officers were thoughtful in their postoperative pain management as well as in their use of appropriate sedation for children undergoing painful procedures, many were not and there was significant variability among styles and approaches. Intramuscular analgesics and meperidine were still used occasionally. Clearly, a more uniform approach was necessary.
Uniformity of Pain Assessment.
There was also a lack of uniformity of pain assessment approaches and techniques among the nursing staff. Pain was often not automatically assessed and when it was assessed, a variety of techniques were used. This lack of uniformity made it hard to interpret whether children had been treated adequately for their discomfort. For example, some nurses might use a 4-point scale while others might use a 10-point scale. Some nurses would evaluate the child's pain themselves, even in older children, while other nurses would ask the child specifically to report the level of his/her discomfort. It was difficult for a chart reviewer to determine whether or not a child had suffered unnecessarily given the variety of assessment approaches that were evident from the chart. In addition, there was no specific location on the chart where pain assessment was reliably reported. Often, it was buried within the nurses notes in a narrative and had to be actively searched for. Pain assessment needed to be more uniform and more visible.
Decreasing the Pain of Needle Procedures.
Another problem that was evident was the lack of adequate planning regarding needle procedures. For many children, needles are symbolic of hospitalization.16 There is an elaborate literature available that suggests that the pain of needles can be significantly ameliorated both by local anesthetics, either injected17 or topically applied,18,19 and by distraction techniques.20 Again, in our institution, we found significant variability regarding the use of local anesthetics for venipuncture and venous cannulation. We also found frequent situations where a laboratory test would be ordered, blood drawn and, 1 hour later, the house officer would realize that an additional test might be desirable and subject the child to an additional needle stick. In addition, although the use of a treatment room is recommended so that the child's room is a refuge from painful procedures, this was only occurring intermittently, again depending the nurse, house officer, or laboratory technician. Decreasing the anxiety and discomfort of needle procedures through the use of local anesthetics and better planning was essential.
Finally, we noticed that parents were often not involved in decisions regarding treatment. It is well known that parents have an important role to play both in helping health professionals understand their child's individual needs and responses and in providing comfort to their child in a way that no one else can.21 Many parents, however, were excluded from the treatment room and not asked questions about their child's individual temperament or behavioral style. Their responses might be helpful in developing an appropriate individualized program to fit the needs of their child. We needed more integral involvement of parents into our planning and in the care that we offered.
Components of the Ouchless Place
The following components of the Ouchless Place were developed to address the previously described goals:
Postoperative Pain and Sedation Regimens.
In response to the variability in postoperative pain control and in sedation for painful procedures, it was decided that an expert committee with representation from anesthesiology, pediatrics, surgery, and nursing be appointed. The committee was entrusted with developing specific protocols that represented current standards within their respective literatures. Its work was aided by recent consensus statements and clinical practice guidelines that had been generated by both academic societies and the federal government for the management of pediatric postoperative pain management,22procedure pain,22,23 and sickle cell disease vaso-occlusive pain.24 Specific St Francis protocols were developed for postoperative pain management, sedation for painful procedures and sickle cell vaso-occlusive pain. For example, postoperative and sickle cell pain are managed with patient-controlled analgesia in children over the age of 7 years and with continuous infusion of morphine in younger children. Specific monitoring and assessment strategies were developed and included in the protocols. Sedation protocols involve the use of fentanyl or morphine and midazolam.
Once these protocols were completed, they received formal approval by the chief of each involved service. The protocols were placed in a protocol book that was prominently displayed on the floor. House officers were informed of their availability and that it was the desire of each of the departments to use these protocols in place of other methods that might be considered. When a house officer who might be accustomed to using intramuscular injections or approaches that were not felt to be as appropriate for pediatrics would rotate through the service, the individual nurses would inform him or her of the availability of the pediatric pain protocols. If he or she chose not to use those protocols, the nursing staff acting as patient advocate could question why the house officer was choosing a method other than the standard of care and if unable to justify an alternative approach, more senior members of their discipline could be contacted. Most of the time, house officers and attendings were happy to have these protocols and be spared the humiliation of not knowing appropriate doses or approaches to children. Thus, by having easy availability of well recognized highly visible protocols and by empowering nurses to remind house officers of their availability, much of the variability that we had previously seen regarding adequacy of pain management dissipated.
A nursing subcommittee of the pain interest group was set up to review available pain assessment techniques and select an instrument for use on the inpatient unit. In reviewing the literature, it became clear that the child's self-report of his or her discomfort was the most appropriate way to assess pain.25,26 For children over the age of 8, this could be done by using the visual analogue scale, a 10-cm line with or without reference points, and selecting the point on the line or the number on the line that represented the amount of pain they were experiencing.27 For children aged 3 to 7 years, however, a number of modified visual analogue scales were available using cartoon faces,28 pictures of children,29poker chips,30 and colors.31
After piloting a number of different instruments, the nurses felt that the Wong-Baker Scale,32 a group of five cartoon faces ranging from happy to sad, and the visual analogue scale with numbers from 1 to 10 were the easiest to use and selected them for permanent use in children 3 to 7 years and over 8, respectively. For children under the age of 3, the nurse's impression of the child's discomfort based on behavioral and physiologic parameters was the identified approach.
The group then set about creating a more visible place for pain assessment on the patient record. In conjunction with recommendations Agency for Health Care Policy and Research guidelines,22they determined that pain should be a vital sign and were able with much effort to redesign the vital sign flow sheet, introducing a pain column prominently displayed on the nursing assessment flow sheet. On the back of the clipboard that contained the vital sign flow sheets were copies of the two self-report scales so that nurses would have them available whenever they were recording vital signs on a child. Such an approach allowed the nurses ownership of pain assessment with simultaneous easy access to this information by other members of the health care team. By identifying the scales that were easiest to use, nurses did not feel that this was another responsibility that was thrust upon them but instead recognized it as an important part of the nursing process and took some pride in their ability to influence children's comfort in the hospital.
Decreasing Needle Pain.
With the availability of EMLA, a topical local anesthetic, over the past 2 years, needles procedures can often be essentially painless.18,19,33 Unfortunately, EMLA requires 1 hour to work maximally and this often causes some logistical problems in busy settings. In response to this problem, the committee developed an approach that allows for a standing order for EMLA on all patients who require scheduled blood work. Therefore, for example, the night shift will apply EMLA to two sites on all of the children with scheduled blood work at 7 am. When the day shift comes on to draw the blood, the children will have had 1 hour exposure and the pain associated with the needle stick will be minimized. Although some anxiety remains associated with seeing the needle and anticipating pain, in general, this approach dramatically reduces the pain associated with needle sticks that decreases the general fearfulness children experience when admitted in the hospital. House officers were also encouraged to critically evaluate the blood work that they order. They were informed that ordering additional blood work without a highly defensible explanation (a change in the clinical condition of the child or in response to the results of previous laboratory information) on a child who had just been stuck would be looked on with disfavor by the supervising physicians.
Perhaps the most important concept that emerged from the working group was the empowerment of parents. A pamphlet was developed that would be given to parents upon the child's admission to the hospital. The pamphlet emphasized the hospital staff's pledge to consider both comfort measures as well as the curative aspects of care. It described some of the measures that have been mentioned previously (use of standardized pain assessment techniques, standardized protocols, use of local anesthetic creams, etc) and invited parents to participate at all levels of their child's care. It stated directly that the staff would like the parent's help in developing an appropriate program for their child because parents understand better than anyone else their child's needs. It asked parents to participate in decision-making and if they desired, to be present during all procedures done on their child. It described some techniques that could be used to comfort children of different ages. The basic idea was to empower parents to take an active role in their child's care and advocate for them during a time when most parents feel helpless and out of control. We wanted them to feel comfortable in expressing any concerns and to feel assured that their concerns would be taken seriously.
When these concepts were developed and specific strategies identified for achieving them, there was a formal announcement of this new approach culminated by a renaming of the inpatient pediatric unit as The Ouchless Place, demarcated by a large sign prominently displayed. There were numerous in-services to nursing and medical staff.
The initial response to this approach was very positive. Overall, there appears to have been a philosophical change in thinking about pain. Nurses feel less helpless to react to a child's discomfort and are less dependent on the vagaries of the house and attending staff. Medical staff have standardized protocols to call upon that have become the standard of care. Pain assessment has become routinized and through the quality assurance mechanism the adequacy of pain assessment and relief can be monitored. Despite an increased usage of opioids, we have not seen an increase in adverse opioid-related events. We feel that this is due to the greater attention given to the administration and monitoring of these agents that the Ouchless Place protocols have provided. Formal assessment of the effects of these interventions will be undertaken in the future. These data will be useful in determining the generalizability of our experiences to other settings.
Lessons Learned and Implications for Other Centers
A number of problems were encountered during this process.
Although EMLA is used on almost every planned blood draw and venipuncture, there were occasional lapses, in particular, when blood is drawn by laboratory technicians instead of the nursing service. Laboratory technicians who tend to be more hurried often will go directly to the patient's room without first stopping at the nursing station. There were numerous instances where blood was drawn in the patients room, not the treatment room, and although there might have been a Tegederm patch with EMLA on the patient, the laboratory technician ignored or did not see it and used a nonanesthetized site. Despite letters to the laboratory, these errors continue to occur again suggesting that it is extremely difficult to entirely control the hospital environment, even in a small unit over which the pediatric and nursing departments have control.
The funding of EMLA has, to the present time, been considered a legitimate pharmacy charge and we have had no problems with reimbursement but in these increasingly cost conscious times, we do have concerns that this may become more of an issue.
An additional problem that stems from the lack of formal leadership has been one of complacency. With no one individual or discipline in charge of the Ouchless Place because the philosophy is transdisciplinary, there has been no standardized way to monitor its components or overall efficacy. The quality assurance route has been used to look at pain documentation and analgesic usage. There is no assigned individual who necessarily orients new personnel (nursing and house officers), certifies that the nurses are handing out the Ouchless Place brochures, monitors the continued high level of involvement of parents in this process, and reminds each new group of students and house officers in anesthesia, surgery, and pediatrics about the availability of protocols. The transdisciplinary nature of the Ouchless Place creates difficulties in maintaining adherence to its basic concepts. Continued vigilance is critical and we have found it necessary to resurrect the original pain interest group that designed the Ouchless Place to provide ongoing oversight.
In summary, this article presents a description of an attempt to systematically reduce the pain associated with hospitalization. The idea was to create a unified approach across disciplines and shifts focused on children's pain relief. A multidisciplinary committee was formed to identify the barriers to adequate pain control. Through the use of standardized pain assessment techniques and pain relief protocols, much of the variability that was inherent in the previous system was eliminated. Once such an integrated system is in place, quality assurance mechanisms can monitor it's efficacy. Although we feel we have made dramatic improvements in our unit, a continuing effort is necessary to remind the nursing and medical staff of the importance of the the Ouchless Place philosophy as an underpinning of our approach to medical care. Continued careful oversight remains necessary as no one discipline is responsible for all of the components. This approach does not rely on expensive pain services or highly technical methods of providing care and is therefore applicable to any setting in which ill children are cared for. By attending carefully to their comfort and anxiety, we feel we can dramatically decrease the burden that illness imposes on hospitalized children and their families and create a more pleasant environment for the children, parents, and staff alike.
- Received August 6, 1996.
- Accepted October 24, 1996.
Reprint requests to (N.L.S.) Center for Children's Health and Development, St Francis Hospital and Medical Center, 114 Woodland St, Hartford, CT 06105.
- EMLA =
- eutectic mixture of local anesthetics
- ↵Eland JM, Anderson JE. The experience of pain in children. In: Jacox A, ed. Pain: A Sourcebook for Nurses and Other Health Professionals. Boston, MA: Little, Brown; 1977
- Anand KJS,
- Hickey PR
- Rana S
- Schechter NL,
- Allen D,
- Hanson K
- Clark S,
- Radford M
- French GM,
- Painter EC,
- Coury DL
- Schechter NL,
- Bernstein B,
- Beck A,
- et al.
- ↵Acute Pain Management Guideline Panel. Acute Pain Management. Operantive and Medical Procedures and Trauma. Clinical Practice Guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1992. AHCPR publication 92–0032
- ↵World Health Organization. Cancer Pain Relief and Palliative Care in Children. Geneva, Switzerland: World Health Organization; 1996
- ↵Shapiro BS, Schechter NL, Ohene-Frempong K, eds. Conference Proceedings: Sick Cell Disease Related Pain–Assessment and Management. Boston, MA: Genetic Resource of the New England Regional Genetics Group; 1994:1–53
- McGrath PJ,
- Cunningham SJ,
- Goodman JT,
- et al.
- ↵McGrath PA, deVeber L, Hearn M. Multidimensional pain assessment in children. In: Fields H, Dubner R, Cervero F, eds. Advances in Pain Research and Therapy. New York, NY: Raven Press; 1985:387–393
- Beyer J,
- Aradine C
- Halperin DL,
- Koren G,
- Attias D
- Copyright © 1997 American Academy of Pediatrics