2016 Awards Luncheon Lecture - Knowing Is Not Enough: Changing Institutional Practice Regarding Pediatric Pain
Reviewed by Ben Jackson, MD
Attendees at the 2016 SPS Annual Conference were treated to an inspiring presentation at the Awards Luncheon by Neil Schechter, MD, Director of the Chronic Pain Clinic in the Division of Pain Medicine at Boston Children’s Hospital. Connecting the traumatic experience of his daughter as a toddler being papoosed for laceration repair to the gross under-treatment of pain in children during the era of his pediatrics training, Dr. Schechter cultivated a passion for addressing the problem of pediatric pain management, and that passion has translated into a compelling approach to making a change far too long overdue.
Conveying the need for improvement, Dr. Schechter reviewed the lamentable history of pain (mis-)management in children, a minimalistic approach based on synergistic myths that “children don’t feel pain” and “analgesics are too strong for children." This unconscionable aspect of our healthcare past all too frequently persists into the present in settings where even enhanced knowledge about pain in children is stifled by a multifactorial lack of commitment to progress and appropriate care. And yet, there have been considerable strides made over the past 30 years of work and discovery in the field of pediatric pain, which Dr. Schechter highlighted:
- Enhanced understanding of the nervous system’s processing of pain
- Progress in knowledge of safety, efficacy, dose response, pharmacogenomics, and clinical outcomes of analgesics and anesthetics in neonates, infants, and children
- Coupling the multi-factorial nature of pain with the development of multidisciplinary pain treatment teams
- Development of successful behavioral and physical strategies for chronic pain
- Ability to assess and treat the overwhelming majority of pain problems in children regardless of age and cognitive ability
Despite this progress, however, pediatric procedural pain remains a problem inconsistently and variably addressed. What is more, in this era when patient/parent satisfaction garners much attention, the greatest disparity between parent treatment priority and parent report of satisfaction with care of their children is the matter of pain management. Dr. Schechter was insistent that, though there is still progress to be made in the area of knowledge acquisition, it is the application of what is already known that is lacking to address the present status of the problem sufficiently.
Dr. Schechter summarized and critiqued commonly employed, isolated strategies to implement change. Medical educational efforts, such as curriculum modification, lectures, and conferences, offer potential for change but are limited in terms of effectiveness unless repetition is involved or content is directly relevant to current clinical care. Interactive, case-based educational outreach sessions in small group settings are more effective but are labor-intensive and expensive; their efficacy may be enhanced by consumer/patient education efforts, which demands more work and funding.
Additionally, defining “best practice” through guideline development and revision is important to establish evidence-based recommendations, but practice change to comply with guidelines has not been shown to occur in the absence of well defined implementation strategies that include defining minimal competency standards, robust quality improvement/assurance initiatives, monitoring adverse events, and measuring adherence. Quality improvement activities with audit and feedback have the potential to promote meaningful change but are often limited in effectiveness by delay of feedback and lack of consequence for failure to respond to feedback recommendations.
Dr. Schechter concluded his presentation by sharing a novel approach to implementing real change and introducing ChildKind, an organization conceived by the Special Interest Group on Pain in Childhood of the International Association for the Study of Pain as a strategy to reduce pain in children by formally recognizing healthcare facilities that have made an institutional commitment to providing pain relief. An “institutionalized” approach to pain management in children involves a comprehensive combination strategy, in essence, a culture change in which pain relief is woven into the fabric of care and becomes the responsibility of everyone—not just that of the pain or sedation service.
In such a construct, pain management and comfort measures are employed in every patient encounter, rendering poor attention to pain an outlier in the institution that prioritizes compassionate comfort care. An institutional initiative of this magnitude necessitates administrative buy-in with pain management identified as a core value incorporated into the mission statement and establishment of a Pain Steering Committee with representatives from all divisions and departments. At the clinical level, standardized pain assessment instruments are used across the enterprise, treatment protocols are developed and prominently displayed, pain is discussed in nursing interview admission process, pain issues are addressed on rounds, and pain is incorporated into handoff transitions of care.
Educational aspects involve all trainees, physicians, nurses, employees, and families, online learning modules, readily accessible references via handbook/smartphone app, and participation in Pain Awareness Week. Quality metrics are identified, frequently reviewed, and monitored. Advocacy is achieved through campaigns, signage, and increased communication efforts to the greater community. Hospitals that can provide evidence of these commitments and practices may apply for ChildKind Accreditation status, an award that benefits pediatric patients, families, and the members of the institution’s patient care team—all the stakeholders in children’s hospitals. (For further information about ChildKind and criteria for application, please visit www.childkindinternational.org)
In his inspiring call to action, Dr. Schechter shared a quote from German writer Johann Wolfgang von Goethe: “Knowing is not enough; we must apply. Willing is not enough; we must do.” The SPS can give thanks to Dr. Schechter for both sharing with us his robust knowledge about pain management in children and equipping us with a strategy to implement an improvement in pediatric pain care. The challenge is now ours to respond to his invitation to do what is needed.