Procedural Pain Management: Clinical Practice Recommendations.

Undergoing potentially painful procedures is necessary among patients of all ages. Nurses are responsible to optimize safety and minimize harm for patients. The American Society for Pain Management Nursing (ASPMN) holds the position that all patients undergoing painful procedures have the right to safe and effective pain management throughout the phases of care, and that the interprofessional healthcare team ensures such ethical obligation is fulfilled within a framework of the patients or their designees' goals and preferences. From that position, all nurses, clinicians, and health care organizations are strongly encouraged to offer multimodal pain management that includes integrative interventions when managing procedure related pain.

Procedural Pain Management: Clinical Practice Recommendations American Society for Pain Management Nursing.

Throughout the life span procedures are common within health care and have the potential to cause pain. Nurses have an ethical responsibility involving the care of people with pain. The American Society for Pain Management Nursing holds the position that all patients undergoing painful procedures have the right to safe and effective pain management throughout the phases of care and that the interprofessional health care team ensures such ethical obligation is fulfilled within a framework of patients or their designees' goals and preferences. It is recommended that nurses, other health care providers, and health care organizations offer the use of integrative intervention for managing pain during procedures.

Effects of the FDA Codeine Safety Investigation on Racial and Geographic Disparities in Opioid Prescribing after Pediatric Tonsillectomy and/or Adenoidectomy.

Objective. Our objective was to examine the impact of the U.S. FDA's 2013 black box warning against codeine on codeine and other opioid prescription filling after pediatric tonsillectomy and/or adenoidectomy (T/A) overall and by child race and provider urbanity/rurality. Methods. Patients ≤ 18 who underwent T/A in 8/2011 to 8/2016 were identified in Ohio Medicaid claims. Interrupted time series analyses were used to evaluate the impact of the FDA warning on codeine or other opioid prescription filling post-T/A. Results. In August 2011, codeine prescription filling was lower among black than white children (P < .001) and among children treated at institutions in metropolitan counties than less populous counties (P < .001). The FDA warning was associated with a 24.0% drop in codeine prescription filling (P < .001) and 5.5% increase in alternative opioid prescription filling (P = .046). At conclusion, there remained geographic but no longer racial disparities in codeine prescribing. Conclusion. Codeine prescribing after pediatric T/A decreased after the FDA's black box warning. However, geographic disparities in codeine prescribing remain.

Chronic Pain and Mental Health Co-Morbidity in Adolescents: An Urgent Call for Assessment and Evidence-Based Intervention.

BACKGROUND: Nearly 30% of children are affected by chronic pain which puts a significant burden on the child's family and society with estimated cost of over $19.5 billion each year. Children and adolescent's quality of life is often impacted leading to physical disability, low self-esteem, depression, anxiety, school stress or decreased performance, insomnia, and fatigue. The purposes of this paper are to: 1) provide an overview of chronic pain in children and adolescents; 2) describe findings from a quality improvement project that assessed the prevalence of negative mood, quality of life, functional disability, and coping with pain in teens with chronic pain, and 3) discuss screening, assessment and evidence-based management of co-morbid chronic pain and mental health problems in children and teens. FINDINGS: Findings for a quality improvement project indicated that 16.8% of the adolescents scored high risk for depression, which was higher than the national average. Approximately 57% of adolescents were screened as high risk on the Pediatric Quality of Life inventory (PedsQL™). One in four adolescents showed poor functioning on the Functional Disability Inventory and nearly one-third of the adolescents reported poor coping with pain on the Pain Coping Questionnaire. This project indicates that adolescents with chronic pain are at high risk for mental health problems. The outcomes suggest the mental health needs of adolescents with chronic pain need to be identified and addressed to help improve outcomes. DISCUSSION: Children and youth with chronic pain need to be routinely screened and assessed for mental health problems, especially anxiety and depression. The use of Cognitive Behavioral Therapy (CBT) or CBT-skills building for children and youth with anxiety and depressive disorders has been widely studied and are helpful for children with chronic pain include psychoeducation, which helps the child to learn age and developmental specific information on chronic pain. Evidence-based manualized and internet-based CBT programs should be scaled rapidly to decrease depression and anxiety in children and youth with chronic pain.

Evaluation of racial disparities in postoperative opioid prescription filling after common pediatric surgical procedures.

BACKGROUND: Racially disparate pain management affects both adult and pediatric patients, but is not well studied among pediatric surgical patients after discharge. The objectives were to evaluate racial disparities in pediatric postoperative opioid prescription filling. METHODS: This retrospective cohort study included black or white pediatric Medicaid patients who underwent tonsillectomy, supracondylar humeral fracture fixation, or appendectomy (2/2012-7/2016). Patients were followed for 14 days post-surgery to identify opioid prescription fills. Logistic regression models evaluated the association between race and the probability of filling an opioid prescription. RESULTS: Among 39,316 surgical patients, the proportions of patients with post-surgical opioid prescriptions were 66.0%, 83.9%, and 68.5%, among tonsillectomy, supracondylar fracture, and appendectomy patients, respectively. The proportion of black appendectomy patients with a postoperative opioid prescription was significantly lower compared to white patients (65.0% vs. 69.2% respectively, p = 0.03), but was no longer significant after adjusting for other patient and provider characteristics. There were no differences by race in opioid prescription filling among other surgical patient groups. CONCLUSIONS: The present study did not identify racial disparities in opioid prescription filling in adjusted analyses. Racial differences in unadjusted postoperative opioid prescription filling among appendectomy patients may be explained in part by longer postoperative length-of-stay among black children. TYPE OF STUDY: Prognosis Study LEVEL OF EVIDENCE: Level II.

Barriers to Outpatient Pediatric Chronic Pain Clinic Participation Among Referred Patients.

Initial clinic evaluation among referred patients and factors limiting treatment initiation are not well characterized. We conducted a retrospective review of referrals to our outpatient pain clinic to identify intake visits and factors associated with treatment initiation among adolescents with chronic pain. We identified adolescents aged 13 to 18 years at the time of referral to clinic (2010-2016). Factors associated with completion of visits were evaluated using logistic regression. Patients who completed visits more frequently had private insurance than public or no insurance (P = .053). The most common reasons for caregiver decision not to attend the pain clinic included use of another pain clinic, that services were not wanted or no longer needed, and that their child was undergoing further testing. The current study demonstrated that patients with head pain were more likely to complete an intake visit, while there was a trend showing that lack of private insurance decreased this likelihood.

Opioid Prescription Filling Trends Among Children with Sickle Cell Disease After the Release of State-Issued Guidelines on Pain Management.

OBJECTIVE: To assess the impact of Ohio's 2012, 2013, and 2016 opioid prescribing guidelines on opioid and nonsteroidal anti-inflammatory drug (NSAID) prescription filling and health care utilization for pain among children with sickle cell disease (SCD). DESIGN: Quasi-experimental retrospective cohort study. SETTING: Ohio Medicaid claims data from August 2011 to August 2016. SUBJECTS: Medicaid beneficiaries under age 19 years with SCD. METHODS: Interrupted time series analyses comparing population-level rates of opioids and NSAID prescriptions filled, standardized amounts of opioids dispensed, and acute health care utilization for pain before and after release of each guideline. RESULTS: In our cohort of 1,505 children with SCD, there was a temporary but significant decrease in the opioid filling rate (-2.96 prescriptions per 100 children, P = 0.01) and in the amount of opioids dispensed (-31.39 milligram morphine equivalents per filled prescription, P < 0.001) after the 2013 guideline but a temporary but significant increase in the opioid filling rate (7.44 prescriptions per 100 children, P < 0.001) and in the amount of opioids dispensed (72.73 mg morphine equivalents per filled prescription, P < 0.001) after the 2016 guideline. The NSAID filling rate did not significantly change after any of the guidelines. Acute health care utilization rates for pain after the 2016 guideline were similar to those before the 2013 guideline (rate ratio = 1.04, P = 0.63). CONCLUSIONS: Our results suggest that Ohio's 2013 and 2016 guidelines were associated with significant but nonsustained changes in opioid prescription filling among children with SCD. Additional studies are needed to confirm that opioid guidelines have a sustained impact on excessive opioid prescribing, filling, and misuse.

Racial Disparities in Receipt of Postoperative Opioids After Pediatric Cholecystectomy.

BACKGROUND: Pediatric postoperative opioid prescribing has come under scrutiny as a result of the ongoing opioid epidemic. Previous research has demonstrated that African American adults are less likely to receive analgesics, particularly opioids, after surgery, even after controlling for pain severity. We sought to examine racial disparities in the filling of opioid prescriptions by pediatric surgical patients after cholecystectomy. METHODS: We studied patients aged 1 to 18 y who were enrolled in Ohio Medicaid and underwent cholecystectomy. Procedures performed in January 2013-July 2016 were included. The percentage of patients who filled a postoperative opioid prescription within 14 d of their procedure was compared between black and white patients using log binomial regression models fit using generalized estimating equations to account for patient clustering within hospitals. RESULTS: We identified 1277 patients who underwent a cholecystectomy. In unadjusted analyses, black children were significantly less likely than white children to fill an opioid prescription postoperatively (74.9% versus 85.7%, P < 0.001). After adjustment for patient-level clinical and demographic characteristics, we found that black children treated at non-children's hospitals in large-/medium-sized urban counties were significantly less likely to fill an opioid prescription after cholecystectomy when compared with white children treated at urban children's hospitals or to white children treated in non-children's hospitals in either large/medium urban counties or other counties. However, this association was partly explained by a longer average length of stay among black children. CONCLUSIONS: Black children who undergo cholecystectomy at urban non-children's hospitals are less likely to fill a postoperative opioid prescription than white children who undergo cholecystectomy at those same hospitals or other hospitals. Further research is needed to identify whether this disparity is due to a lower rate of opioid prescribing or a lower rate of prescription filling.

Current interventions to promote safe and appropriate pain management.

PURPOSE: Describe patient-, clinician-, system-, and community-level interventions for pain management developed and employed by 9 healthcare systems across the United States and report on lessons learned from the implementation of these interventions. SUMMARY: The high cost associated with pain coupled with the frequent use of opioid analgesics as primary treatment options has made novel pain management strategies a necessity. Interventions that target multiple levels within healthcare are needed to help combat the opioid epidemic and improve strategies to manage chronic pain. Patient-level interventions implemented ranged from traditional paper-based educational tools to videos, digital applications, and peer networks. Clinician-level interventions focused on providing education, ensuring proper follow-up care, and establishing multidisciplinary teams that included prescribers, pharmacists, nurses, and other healthcare professionals. System- and community-level interventions included metric tracking and analytics, electronic health record tools, lockbox distribution for safe storage, medication return bins for removal of opioids, risk assessment tool utilization, and improved access to reversal agents. CONCLUSION: Strategies to better manage pain can be implemented within health systems at multiple levels and on many fronts; however, these changes are most effective when accepted and widely used by the population for which they are targeted.

Barriers to Pediatric Pain Management: A Brief Report of Results from a Multisite Study.

BACKGROUND: Pain management is essential for the care of hospitalized children. Although multiple barriers have been identified that interfere with nurses' ability to provide optimal pain management, it is not known how pervasive are these barriers across the United States. AIMS: This study is the third in a series of studies examining barriers to pediatric pain management. The aim of this study was to examine barriers in different organizations using the same tool during the same period of time. SETTINGS/PARTICIPANTS: A sample of 808 nurses from three pediatric teaching hospitals responded to a survey addressing barriers to optimal pain management for children. RESULTS: Barriers unanimously identified as being most significant included inadequate or insufficient physician medication orders, insufficient time allowed to premedicate before procedures, insufficient premedication orders before procedures, and low priority given to pain management by medical staff. CONCLUSIONS: Barriers identified as the most and least significant were similar regardless of hospital location. Revealing similar barriers across multiple pediatric hospitals provides direction for nurses trying to provide solutions to these pain management barriers.

Predictors of Referral to a Pediatric Outpatient Chronic Pain Clinic.

OBJECTIVES: The main objectives of this study were to retrospectively characterize the rate of referrals to an outpatient chronic pain clinic among adolescents with chronic pain, and to identify factors associated with referral. MATERIALS AND METHODS: Adolescents, 13 to 18 years of age seen in 2010 to 2015 at outpatient clinics associated with Nationwide Children's Hospital (NCH) and diagnosed with chronic pain were included if they lived near NCH and had not been previously referred to the NCH outpatient chronic pain clinic. Subsequent referrals to the pain clinic were tracked through December 2017 using a quality improvement database. Factors predicting referral were assessed at the initial encounter in another outpatient clinic and analyzed using multivariable logistic regression. RESULTS: The analysis included 778 patients (569 female; median age, 15 y), of whom 96 (12%) were subsequently referred to the chronic pain clinic, after a median period of 3 months. Generalized chronic pain (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.1; P=0.023) and regional pain syndromes (adjusted odds ratio, 3.1; 95% confidence interval, 1.5-6.7; P=0.003) were associated with increased likelihood of referral. The referral was also more likely among female patients and among patients with a mental health comorbidity or recent surgery or hospitalization. DISCUSSION: Referrals to our chronic pain clinic were more likely for adolescents with generalized chronic pain, regional pain syndromes, and patients with mental health comorbidities. Recent hospitalization or surgery, but not recent emergency department visits, were associated with pain clinic referral. The multivariable analysis did not find disparities in referral by race or socioeconomic status.

Health Care Utilization and Costs Associated With Pediatric Chronic Pain.

The population prevalence of pediatric chronic pain is not well characterized, in part because of a lack of nationally representative data. Previous research suggests that pediatric chronic pain prolongs inpatient stay and increases costs, but the population-level association between pediatric chronic pain and health care utilization is unclear. We use the 2016 National Survey of Children's Health to describe the prevalence of pediatric chronic pain, and compare health care utilization among children ages 0 to 17 years according to the presence of chronic pain. Using a sample of 43,712 children, we estimate the population prevalence of chronic pain to be 6%. In multivariable analysis, chronic pain was not associated with increased odds of primary care or mental health care use, but was associated with greater odds of using other specialty care (odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.62-2.47; P < .001), complementary and alternative medicine (OR = 2.32, 95% CI = 1.79-3.03; P < .001), and emergency care (OR = 1.62, 95% CI = 1.29-2.02; P < .001). In this population-based survey, children with chronic pain were more likely to use specialty care but not mental health care. The higher likelihood of emergency care use in this group raises the question of whether better management of pediatric chronic pain could reduce emergency department use. PERSPECTIVE: Among children with chronic pain, we show high rates of use of emergency care but limited use of mental health care, which may suggest opportunities to increase multidisciplinary treatment of chronic pain.

Rapid Response Team activation for pediatric patients on the acute pain service.

INTRODUCTION: Untreated pain or overly aggressive pain management may lead to adverse physiologic consequences and activation of the hospital's Rapid Response Team. This study is a quality improvement initiative that attempts to identify patient demographics and patterns associated with Rapid Response Team consultations for patients on the acute pain service. METHODS: A retrospective review of all patients on the acute pain service from February 2011 until June 2015 was cross-referenced with inpatients requiring consultation from the Rapid Response Team. Two independent practitioners reviewed electronic medical records to determine which events were likely associated with pain management interventions. RESULTS: Over a 4-year period, 4872 patients were admitted to the acute pain service of whom 135 unique patients required Rapid Response Team consults. There were 159 unique Rapid Response Team activations among 6538 unique acute pain service consults. A subset of 27 pain management-related Rapid Response Team consultations was identified. The largest percentage of patients on the acute pain service were adolescents aged 12-17 (36%). Compared to this age group, the odds of Rapid Response Team activation were higher among infants <1 year old (odds ratio = 2.85; 95% confidence interval: 1.59, 5.10; P < .001) and adults over 18 years (odds ratio = 1.68; 95% confidence interval: 1.01, 2.80; P = .046). DISCUSSION: Identifying demographics and etiologies of acute pain service patients requiring Rapid Response Team consultations may help to identify patients at risk for clinical decompensation.

Home peripheral nerve catheters: the first 24 months of experience at a children's hospital.

CONTEXT: Home peripheral nerve catheters (PNCs) have become common practice for adult patients after major orthopedic surgery. However, use in pediatric patients is a recent application. OBJECTIVES: The purpose of this study was to review the demographics and outcomes of pediatric patients receiving a PNC at our institution. METHODS: This retrospective study included patients from October 2012 through October 2014 undergoing orthopedic procedures with a PNC placed for postoperative pain management. RESULTS: A total of 118 patients aged 3.2-25.3 years were identified. The types of catheters included femoral (80.5%), interscalene (11.9%), sciatic (5.9%), and supraclavicular (1.7%). The majority of patients were discharged to home on the day of surgery (77.1%). In the postanesthetic care unit, the average pain score was 2.5, the incidence of nausea/emesis was 5.9%, and the need for opioid administration was 50.8%. There were no major complications. Minor complications included a 7.6% rate of early catheter removal with 5.9% of those due to catheter leakage and an unsecure dressing. There was one case of metallic taste in the mouth without other symptoms of local anesthetic toxicity that resolved without further complication. CONCLUSION: The implementation of a home PNC program in pediatric patients at our institution has been highly successful with a high rate of ambulatory catheters, low pain scores, low rates of nausea and vomiting, and no serious complications. Minor complications included leaking of the catheter and early discontinuation of the catheter.

Safety and efficacy of nurse-controlled analgesia in patients less than 1 year of age.

BACKGROUND: The management of acute pain presents unique challenges in the younger pediatric population. Although patient-controlled devices are frequently used in patients ≥6 years of age, alternative modes of analgesic delivery are needed in infants. OBJECTIVE: To examine the safety and efficacy of nurse-controlled analgesia (NCA) in neonates less than 1 year of age. METHODS: Data from patients <1 year of age receiving NCA as ordered by the Acute Pain Service at our institution were collected over a 5-year period and reviewed retrospectively. The primary outcomes were activation of the institution's Rapid Response Team (RRT) or Code Blue, signifying severe adverse events. Pain score after NCA initiation was a secondary outcome. RESULTS: Among 338 girls and 431 boys, the most common opioid used for NCA was fentanyl, followed by morphine and hydromorphone. There were 39 (5%) cases involving RRT or Code Blue activation, of which only one (Code Blue) was activated due to a complication of NCA (apnea). Multivariable logistic regression demonstrated morphine NCA to be associated with greater odds of RRT activation (OR=3.29, 95% CI=1.35, 8.03, P=0.009) compared to fentanyl NCA. There were no statistically significant differences in pain scores after NCA initiation across NCA agents. CONCLUSION: NCA is safe in neonates and infants, with comparable efficacy demonstrated for the three agents used. The elevated incidence of RRT activation in patients receiving morphine suggests caution in its use and consideration of alternative agents in this population.

Effectiveness of oral sucrose for pain management in infants during immunizations.

This study examined the effects of oral sucrose as an analgesic agent during routine immunization for infants at 2, 4, and 6 months of age. A sample of 113 healthy infants were recruited from three ambulatory clinics and randomly assigned to one of three treatment groups. Infants were given 2 mL orally of either 50% sucrose, 75% sucrose, or sterile water 2 minutes before administration of immunizations. No significant difference was found among the different age groups with the different treatments for pain as measured with the FLACC scores and crying time. Consolability factors are felt to have some influence.

Procedural pain management: a position statement with clinical practice recommendations.

The American Society for Pain Management Nursing (ASPMN) has developed a position statement and clinical practice recommendations related to procedural preparation and comfort management. Procedures potentially produce pain and anxiety, both of which should be assessed and addressed before the procedure begins. This position statement refers to "comfort management" as incorporating the management of pain, anxiety, and any other discomforts that may occur with procedures. It is the position of ASPMN that nurses and other health care professionals advocate and intervene based on the needs of the patient, setting, and situation, to provide optimal comfort management before, during, and after procedures. Furthermore, ASPMN does not condone procedures being performed without the implementation of planned comfort assessment and management. In addition to outlining this position with supporting evidence, this paper reviews the ethical considerations regarding procedural comfort management and provides recommendations for nonpharmacologic and pharmacologic management during all phases of the procedure. An appendix provides a summary of this position statement and clinical practice recommendations.

A retrospective quality improvement study of ketorolac use following spinal fusion in pediatric patients.

BACKGROUND: There are studies and literature that support the claim that ketorolac use after spinal fusion in the adult population can increase the risk of pseudarthrosis, instrumentation failure, and/or nonunion. There is limited research when using ketorolac in the pediatric population, especially short-term use. METHODS: Chart review of 46 pediatric patients who had prior spinal fusions for scoliosis between July 2003 and August 2005. Twenty-five of the patients received ketorolac and 21 did not. The lengths of stay, incidence of curve progression, and/or incidence of nonunion or instrumentation failure were compared in the 2 groups. RESULTS: At the 1-year follow-up, 95% of the patients returned and at the 3-year follow-up, 52% of the patients returned and there was no clinical or radiographic evidence of curve progression, nonunion, or instrumentation failure. LEVEL OF EVIDENCE: This is a retrospective study looking at results of 2 patient groups. This is a level III study.

Improving processes of care in patient-controlled analgesia: the impact of computerized order sets and acute pain service patient management.

BACKGROUND: In an effort to combat opioid induced side effects within the first 24 h of patient-controlled analgesia (PCA) induction, it has been recommended that care be provided by an Acute Pain Treatment Service (APS) and that computerized PCA order sets with patient monitoring requirements be implemented. To date, there are few published studies on the role of computerized order sets or APS in improving the quality and safety of pediatric PCA use. This retrospective analysis sought to determine if the implementation of computerized order sets would increase appropriate monitoring and problem recognition. METHODS: Analysis included 536 patients prescribed PCA in one of three ways: an anesthesia order set with APS support (n = 285), a general PCA order set (n = 95), or no order set (n = 156). We analyzed the use of order sets by unit; the incidence of appropriate monitoring (> or =12 recordings within 24 h) of respiratory rate, oxygen saturation, and sedation level and the recognition of low respiration rate and low oxygen saturation between the types of PCA order. RESULTS: We found a significant difference in type of PCA order used by unit. Appropriate documentation of respiratory rate and oxygen saturation occurred significantly more often if the order set with APS was used. Low respiration rate was also recognized significantly more frequently (P < or = 05) in the APS order set group. CONCLUSIONS: These findings show that use of a computerized PCA order set with monitoring requirements and an APS can increase monitoring and documentation of important vital signs and increase identification of potential negative events.