An Institutional Quality Improvement Initiative for Pain Management for Pediatric Cancer Inpatients

Abstract

Health care institutions must use the principles of quality improvement to demonstrate appropriate assessment and effective management of pain. Here, we describe the quality improvement initiative implemented at our pediatric institution to improve the quality of pain management. We conducted chart audits for the previous 24 hours during which patients received inpatient care. Over six years, 2,478 charts were audited for 87 24-hour periods (average 1.2 days/month) to answer the following: (1) Was pain intensity assessed as per the institutional pain standard of care, (2) What proportion of audited inpatients had significant pain (>or=5/10), and (3) When significant pain (>or=5/10) occurred, was treatment effective (pain score <or=4/10) within one hour of an intervention? Data were analyzed for quarterly time periods (n=24). Compliance with pain assessment guidelines improved from 77% initially to consistently greater than 90%. The mean proportion of patients with significant pain each quarter was 21%. Sixty-six percent of patients with significant pain had pain treated effectively within one hour of intervention. Lack of documentation of pain reassessment within one hour of the intervention was consistent throughout the study period (overall frequency 22%). Comprehensive pain management guidelines have been established. Leaders of health care organizations need to provide the support and resources needed to incorporate these guidelines and standards into institutional culture. We present a simple quality improvement approach to patient care that can be modified to fit the unique aspects of other institutions.

Treatment of Pain in Children after Limb-Sparing Surgery: An Institution's 26-Year Experience

“…Of particular note is the evaluation of pain intensity by using standardized age-appropriate pain assessment scales and the description of the characteristics of pain. As we have reported previously, in our institutional experience, we identified a trend to improve assessment and documentation of the characteristics of pain, as well as intensity and location of pain (Oakes, Anghelescu, Windsor, & Barnhill, 2008). …”

“…In a series reporting on pain assessment and documentation at our institution, we found the rate of documentation of pain intensity scores had increased between 2000 and 2006 from 77% to over 95%. Compliance with documentation of the location and quality of pain was 97% (range 92%–100%) and 91.3% (range 82%–96%) (Oakes, Anghelescu, Windsor, & Barnhill, 2008). Due to the limited data regarding pain intensity, we are unable to comment on associations of pain severity with the types of surgical procedure or with the specific pain management interventions applied.…”

Palliative nursing care for children and adolescents with cancer

“…24 Initiatives on pain and symptom management in pediatric oncology have been developed in response to the unrelieved moderate to severe pain experienced by children. 25,26 These programs included provider education and guidelines for improved pain assessment and management in pediatric oncology. Studies have examined pharmacological strategies to provide optimal pain relief for children with advanced cancer.…”

“…Recommendations exist to improve symptom management in pediatric oncology patients, yet needs for better assessment, measurement, documentation, and treatment of many physical symptoms still remain. 25,32,33 Psychological The psychological dimension of pediatric palliative care for a child or adolescent with cancer affects how the child feels about himself or herself, coping mechanisms, overall perception of quality of life, and the grief and emotions associated with a life-threatening diagnosis. 19,34,35 Children may have thoughts about death that often appear in their fantasies and in their play.…”

Documentation of postoperative pain in the neonatal brachial plexus palsy population

“…Pain experiences are subjective and often consist of sensory, emotional, cognitive and behavioural components (Committee on Psychosocial Aspects of Child and Family Health 2001, Matziou et al 2004, AMA 2007, Ballweg 2008, Trudeau et al 2009). The undertreatment of pain symptoms and the lack of pain assessment are major concerns in the paediatric population because of children's limited experiences and their ability to adequately express discomfort (Collins et al 2000, Anand 2001, Howard 2003, Stomberg et al 2003, Kokki 2004, Matziou et al 2004, Houlahan et al 2006, AMA 2007, Oakes et al 2008, Trudeau et al 2009). Thus, pain treatment and assessment in the paediatric population have received growing attention over the past two decades, even by the professional organisations: the APS and The Joint Commission (TJC) (AHCPR 1992, APS 1995, Committee on Psychosocial Aspects of Child and Family Health 2001, Gordon et al 2005, TJC 2007).…”