Shaping Practice and Policy Advancing the Canadian Pain Research Agenda

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Shaping Practice and PolicyAdvancing the
Canadian Pain Research Agenda

• Moderators Jane Mealey, Janet Rennick
• Presenters Celeste Johnston, Allen Finley,
  Patrick McGrath, Bonnie Stevens

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Canadian Institutes of Health ResearchStrategic
Training ProgramPain in Child HealthA
Cross-Canada Research Training Consortium

• Principal Investigators
• Patrick McGrath, Ken Craig, Allen Finley,
  Celeste Johnston, Bonnie Stevens, Carl von Baeyer
• Research mentors
• Over 30 active researchers in five centers with
  a shared focus on pediatric pain
• Goal
• To develop a community of scholars in pediatric
  pain
• Activities for Trainees in Pain in Child Health
• Visits to other labs Web based courses
  on pain
• Annual summer/fall institute International
  speakers series
• Supplementary funding for support of trainees
• National lab meeting by means of web distance
  tools
• Trainee membership in the consortium is open to
  people with a commitment to the study of pain in
  child health in Canada, in any discipline and at
  any level in their training.
• Membership makes trainees eligible for (but does
  not guarantee) financial assistance. The major
  training centres are Halifax, Montreal, Toronto,
  Saskatoon and Vancouver.

Have Dal, UT, UBC, Usask, CW, HSC, IWK Need
MCH, McGill Other sponsors?
www.dal.ca/pich/
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Pain in Pediatric Hospitals in Canada What do we
know?

• Celeste Johnston

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Under-recognition of pain in children

• Swafford Allen, 1968
• 2/60 post-op children required Rx of pain
• ..pediatric patients seldom need medication for
  the relief of pain. They tolerate discomfort
  well. The child will say that he does not feel
  well or that he is uncomfortable, that he wants
  his parents but often he will not relate his
  unhappiness to pain.

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Reverse Ageism in Pain Management

• Eland (1974) gt 13/25 post-op children received no
  analgesia remaining 12 received a total of 24
  doses (half opioid)
• 18 post-op adults received 372 opioid and 299
  non-opioid analgesics
• Beyer et al (1983)gt post-cardiac surgery,
  children received 30 of opioid doses
• Schechter et al (1986)gt 90 children/90 adults
  with identical diagnoses adults received twice
  the number of opioid doses
• Asprey (1991) replicated Elands study and found
  968 analgesics given instead of 24

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Pain in Hospitalized Patients in Canada age 4-14
yearsJohnston et al 1992

• 150 children surveyed
• 87 had pain in the last 24 hours
• 57 reported clinically significant pain
• 19 reported usual pain intensity in the severe
  range
• 38 had received analgesics
• only half reporting usual or worst pain as severe
  received analgesic
• 63 of surgical patients vs 23 medical patients
  received medication even though intensity was
  similar

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Pain in Hospitalized Pediatric Post-Op Patients
Bennett-Branson Craig, 1993

• 60 Children 7-16 years
• Current pain 5.1/10
• Worst 8.8/10

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Pain in Hospitalized Pediatric Patients
Cummings, Reid, Finley, McGrath, 1996

• 200 children
• Aged gt5, self reported
• 21 had clinically significant usual pain
• 49 had clinically significant worst pain
• Given less medication than Rx over half
  reporting clinically significant pain did not
  receive analgesics

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Pain in Hospitalized Pediatric Patients How Are
We Doing?Ellis et al 2002

• 237 Children 10 days -17 years
• Parents surveyed lt 7 yrs
• Sampled q2h
• 21-30 had clinically significant pain at every
  assessment
• No difference between medical and surgical
  patients
• Difference gt over time? Between sites?

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2004 Data from same site n76 charts
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Emergency Department Study (Johnston et al,
under review)

• Mean pain score on admission 3.29, 9 severe
  (8-10)
• Mean pain on discharge 2.98, 7 severe (8-10)
• 20 improved by 1.5/10 points but
• 11 worsened by 1.5/10
• 5 who had no pain on admission, had pain on
  discharge

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Pediatric Oncology PatientsMcGrath et al, 1990

• 77 oncology outpatients aged 2-9
• 75 severe pain from bma
• 50 mod-severe pain from treatment
• 25 pain from disease

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Consequences of Previous Pain Experience

• Less the number than the quality (Bittebier
  Vertommen, 1998)
• Cancer survivors remember painful procedures, not
  the disease (Kuttner, 2002)
• Chronic pain intensity related to anxiety,
  depression, self-esteem, and behaviour problems
  (Varni et al, 1996)
• One week after visit to ED, children are
  reporting higher scores of distress from pain
  than intensity of pain
• Number of invasive procedures predicts negative
  psychological sequellae (Rennick, 2002)

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Youngest of the Young

• 26-32 weeks excitatory mechanisms in place but
  inhibitory mechanisms not
• Numerous painful procedures
• US (Franck, 1987 Anand,1996)
• UK (Barker Rutter, 1995)
• Australia (McLaughlin, 1993)
• Canada (Fernandez Rees,1994 Johnston et al,
  1997)

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Prospective Canadian NICU Survey Johnston et al,
1997

• 14/38 NICUs participated in 1 week survey of
  patients with dx other than prematurity 239
• 2134 invasive procedures performed 35 procedures
  had medication orders 7/35 were non-analgesic
  sedatives
• 1/28 LPs and 3/5 chest tube insertions given
  anesthesia

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Consequences of pain in NICU

• Fitzgerald et al (1989). Decreased flexor
  tension reflex following repeated heelstick-
  reversed with EMLA
• Johnston Stevens (1996). Increased procedures
  related to less robust, i.e. less mature
  behaviour
• Johnston et al (1999). Time between procedures
  affects response
• Grunau et al (2000). Analgesics associated with
  more robust behaviour

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Where is the Problem?
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COOPPPN (2001-2003)

• 6 pediatric hospitals in Canada
• Charts reviewed for pain assessments and
  management
• Nurses knowledge and attitude about pain
  (Manwarren, 2001)
• Hospitals matched on assessment scores and
  randomly assigned to bi-weekly one-to-one
  coaching or control

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Nurses Knowledge

plt.06
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Patients Documented Assessment


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Documented Non-Pharmacological Interventions


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Pain Practices Cross-Canada Pediatric
OncologyEllis et al, 2003

• 26/28 pediatric oncology centres (10/11 pediatric
  hospitals included)
• 48 questions on
• Pain assessment and documentation
• Procedural pain
• Treatment related pain
• Patient education and home care
• Staff education
• Institutional support for best practice pain
  management
• Complementary therapies
• Palliative and end-of-life care
• Demographics

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Centre-reported Results

• All used assessment scales, 62 numerical scale,
  39 visual analogue scale
• 15/26 centres reported pain assessed 80 of the
  time
• 11/26 reported pain adequately treated 80 of the
  time or better
• For BMAs and LPs 50 used local anesthetics
• Midazolam used 77, propofol 54 ketamine 35 ,
  lorazapam 23
• 20/26 report 90 patients have venous access
  device

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Does self-report reflect practice?

• Nurses great overestimate their use of assessment
  and interventions (Jacob Puntillo, 1999).
• Belief that oncology patients pain is better
  managed not borne out in data

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Conclusions

• Appear to be improvements over the past decade
• Even recent data reveals significant
  unde-rmanagement of pain in children
• How can pain management be improved for children
  coming to hospital?