Improvements in pain outcomes in a Canadian pediatric teaching hospital following implementation of a multifaceted knowledge translation initiative.

BACKGROUND: A previous audit performed at a tertiary / quaternary pediatric hospital in Toronto, Ontario, demonstrated suboptimal assessment and treatment of children's pain. Knowledge translation (KT) initiatives (education, reminders, audit and feedback) were implemented to address identified care gaps; however, the impact is unknown. OBJECTIVES: To determine the impact of KT initiatives on pain outcomes including process outcomes (eg, pain assessment and management practices) and clinical outcomes (eg, pain prevalence and intensity); and to benchmark additional pain practices, particularly opioid administration and painful procedures. METHODS: Medical records at The Hospital for Sick Children (Toronto, Ontario) were reviewed on a single day in September 2007. Pain assessment and management practices, and pain prevalence and intensity in the preceding 24 h were recorded on a standardized data collection form. Where possible, pain outcomes were compared with previous audit results. RESULTS: Records of 265 inpatients were audited. Sixty-three per cent of children underwent a documented pain assessment compared with 27% in an audit conducted previously (P<0.01). Eighty-three per cent of children with documented pain received at least one pain management intervention. Overall, 51% of children received pharmacological therapy, and 15% received either a psychological or physical pain-relieving intervention. Of those assessed, 44% experienced pain in the previous 24 h versus 66% in the previous audit (P<0.01). Fewer children experienced severe pain compared with the first audit (8.7% versus 26.1%; P<0.01). One-third of children received opioids; 19% of these had no recorded pain assessment. Among 131 children who underwent a painful procedure, 21% had a concurrent pain assessment. Painful procedures were accompanied by a pain-relieving intervention in 12.5% of cases. CONCLUSIONS: Following KT initiatives, significant improvements in pain processes (pain assessment documentation and pain management interventions) and clinical outcomes (pain prevalence, pain intensity) were observed. Further improvements are recommended, specifically with respect to procedural pain practices and opioid utilization patterns.

Pain in hospitalized children: a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital.

BACKGROUND: Pain is under-recognised and undertreated. Although standards now exist for pain management, it is not known if this has improved care of hospitalized children. OBJECTIVES: To benchmark pain prevalence, pain intensity, pain assessment documentation and pharmacological treatment of pain. The aim was to highlight areas of good practice, identify areas for improvement and inform development of hospital standards, education, future audits and the research agenda. METHODS: The present prospective cross-sectional survey of all medical and surgical inpatient units took place on a single day at the Hospital for Sick Children (Toronto, Ontario), a Canadian tertiary and quaternary pediatric hospital. A structured, verbally administered questionnaire was used to obtain information on patient demographics, pain before admission, pain intensity during admission and pain treatment. Charts were reviewed to establish frequency of documented pain assessment, the pain assessment tool used and analgesics given. Subgroup analysis was included for age, sex, visible minority or fluency in English, medical versus surgical services and acute pain service input. RESULTS AND CONCLUSIONS: Two hundred forty-one (83%) of the 290 inpatients or their carergivers were interviewed. It was found that 27% of patients usually had pain before admission, and 77% experienced pain during admission. Of these, 23% had moderate or severe pain at interview and 64% had moderate or severe pain sometime in the previous 24 h. Analgesics were largely intermittent and single-agent, although 90% of patients found these helpful. Fifty-eight per cent of those with pain received analgesics in the preceding 24 h but only 25% received regular analgesia. Only 27% of children had any pain score documented in the preceding 24 h. It was concluded that pain was infrequently assessed, yet occurred commonly across all age groups and services and was often moderate or severe. Although effective, analgesic therapy was largely single-agent and intermittent. Widespread dissemination of results to all professional groups has resulted in the development of a continuous quality assurance program for pain at the Hospital for Sick Children. A re-audit is planned to evaluate changes resulting from the new comprehensive pain strategies.

Waiting for treatment for chronic pain - a survey of existing benchmarks: toward establishing evidence-based benchmarks for medically acceptable waiting times.

As medical costs escalate, health care resources must be prioritized. In this context, there is an increasing need for benchmarks and best practices in wait time management. In December 2005, the Canadian Pain Society struck a Task Force to identify benchmarks for acceptable wait times for treatment of chronic pain. The task force mandate included a systematic review and survey to identify national or international wait time benchmarks for chronic pain, proposed or in use, along with a review of the evidence upon which they are based. An extensive systematic review of the literature and a survey of International Association for the Study of Pain Chapter Presidents and key informants has identified that there are no established benchmarks or guidelines for acceptable wait times for the treatment of chronic pain in use in the world. In countries with generic guidelines or wait time standards that apply to all outpatient clinics, there have been significant challenges faced by pain clinics in meeting the established targets. Important next steps are to ensure appropriate additional research and the establishment of international benchmarks or guidelines for acceptable wait times for the treatment of chronic pain. This will facilitate advocacy for improved access to appropriate care for people suffering from chronic pain around the world.

Management of priapism in a child with sickle cell anemia; successful outcome using epidural analgesia.

PURPOSE: To describe the successful management of priapism secondary to sickle cell anemia in a child using neuraxial analgesia provided via an epidural catheter. CLINICAL FEATURES: A seven-year-old male presented with chest crisis and priapism which, following hemoglobin electrophoresis led to a new diagnosis of sickle cell anemia. Epidural management was attempted as an alternative to surgery after failure of more conventional medical and surgical methods to treat the priapism. The patient's clinical condition improved with this intervention and together with further conservative therapy resulted in complete resolution of the priapism. CONCLUSIONS: Priapism is a well described complication of sickle cell anemia that is painful and difficult to manage. Surgical intervention is the last therapeutic resort and often results in significant long-term morbidity. This case highlights how select cases of priapism can be successfully managed with epidural neuraxial blockade which not only provides superior analgesia for the often painful conservative treatments, but may also per se impart a direct and salutary therapeutic benefit.