1. 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 snissen@thechildrenstrust.org.uk

2. Improving pain management in children with complex disabilities National guidance Local agreed standards Audit tool (methodology) Supportive interventions for changing practice Audit results Overview

3. 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

4. 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)

5. 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

6. 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

7. Local agreed standards All children will have pain tool identified All pains addressed by an intervention All interventions evaluated

8. Why audit? To evaluate whether standards are being met Pain identified as a gap in measured outcomes

9. Methodology Review of nursing care files Eight departments audited Retrospective review of seven days

10. 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

11. Pain indicatorEvidence of pain tool used InterventionIntervention 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

12. Audit results 2010 2010 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%)

13. Evidence based guideline Local context applied to national guidance Pain tools and a decision tree Interventions Coordinated approach

14. 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

15. 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

16. 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

17. Pain indicators per child/week

22. Summary of all results Difference 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%

23. Conclusion > 10% improvement on most aspects Change in practice is slow Pain management has been improved Continued improvement is needed

24. A big push forward… 1.Continue interventions to change practice 2.Individual team efforts 3.Managers review pain scores 4.Continue special interest group 5.Move to adopt EBPCG as policy

25. Thank you for listening