- Email: [email protected]
Pain management in pediatrics – the OPBG experience
ADVANCES IN PAIN MANAGEMENT
Pain management in pediatrics – the OPBG experience
Towards a pain-free hospital During the 1950s, first “pain-free” hospitals were set up in the USA. An innovative project was started in 1992 at the St. Luc Hospital in Montreal (Canada) with the aim of changing the behaviour of both healthcare workers and hospitalised patients (Besner 1993). Gradually, similar projects were set up in several European countries, Italy amongst them, and were soon officially recognized by the World Health Organisation. In September 2000, the Italian Ministry of Health instituted a “Pain-free hospital” study group to develop a specific project involving 20 Italian hospitals. The final guidelines were published in the Italian Official Gazette in June 2001. This project included a survey on pain management which showed that pain assessment and management in the institutions studied were far from optimal. Today, very varied approaches coexist in Italy, even if the concept of a pain-free hospital is gradually gaining ground Positive examples are the hospitals in the region of Emilia-Romagna, where the local Health Service has devised plans of action to fight pain both in hospital and at home, under the “pain-free hospital” project ratified in accordance with the State-Regional Conference held on May 24th 2001. The core of the project is the creation of “pain-free hospital” Boards, that guarantee a specific observatory of pain, coordinating and training health professionals, and promoting the establishment of protocols on pain treatment, with the aim of improving care of patients affected by pain of any origin. Currently, all the local health authorities in the region of Emilia-Romagna have instituted a “pain-free hospital” Board and have recruited more than 250 health workers of different specializations. The nursing staff involved in pain management represent more than 35% of all pain-free hospital board personnel. Moreover, many officially approved private hospitals have joined the project and established their own boards. Voluntary organizations may also join the boards.
Gaetano Ciliento
Abstract Introduction: Sometimes it is not the disease from which the child is suffering that is the main source of pain but rather our diagnostic and care procedures. In fact, nursing care as well as surgical and pharmacological treatment may produce not only physical pain but also mental discomfort; this mental discomfort can be sometimes a poor or a lack of pain assessment and control. Objective: This article remarks on the “Pain-free hospital” international project and explains the process of starting up and adherence of our Hospital, aiming at illustrating chosen strategies and tools for pain assessment and control. Conclusion: We discuss some considerations to underline how common strategies for guidelines creation can make hospitalisation and nursing medical care as less traumatic as possible for the child.
Keywords pain; assessment; scale; child; nursing care
Introduction Until only a few years ago, it was believed that a young child could not feel pain, that it would have no harmful effect on him, and that he would not remember it. Today we know that, starting at the end of the second trimester, the fetus can feel pain, while a six month-old child tries to avoid any action that could make him experience pain. The child may feel pain as an aggression; he feels threatened, punished, persecuted, in danger. Sometimes it is not the disease from which the child is suffering that is the main source of pain but rather our diagnostic and care procedures. In fact, nursing care as well as surgical and pharmacological treatment may produce not only physical pain but also mental discomfort. We should not forget that many of these children do not give their consent, feel abandoned by the people they love, and find themselves in an alien environment, surrounded by strangers who may sometimes play with them but who may also sometimes hurt them.
What is a “pain-free hospital”? A “pain-free hospital” is one which performs pain assessment and pain therapeutic control for every patient, for both acute and chronic pain. The international “pain-free hospital” project is based on the following principles: – Pain is a cross-sectional issue, common to every specialization. – The campaign should involve the entire hospital. – The hospital should relieve all types of pain. – Involvement in the campaign of the entire population is essential. The Bambino Gesù Children’s Hospital is totally committed to the “pain-free hospital” project. In fact, the Charter for children’s rights states: “Children shall have the right to undergo the least invasive and painful diagnostic and therapeutic procedures” “All staff members provide human support to the child and his/her family to prevent the onset of pain, reduce its perception, and avoid fear, anxiety and stress.”
Gaetano Ciliento is at the Healthcare Department, Bambino Gesù Children’s Hospital, Scientific Institute (IRCCS), Rome, Italy. Conflict of interest: none declared
PAEDIATRICS AND CHILD HEALTH 17:S1
S67
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN PAIN MANAGEMENT
In compliance with these principles, the Bambino Gesù Children’s Hospital has involved human and financial resources in order to develop this project in the shortest time possible. At present, a multidisciplinary group is working on a policy of action against pain by the implementation of the best strategies and using the best tools and therapeutic protocols that the scientific community can provide. The group’s work has enabled us to: 1. identify pain assessment scales that can be applied at any age and to any disease 2. assess adequate graphic documentation for pain symptom 3. set times and conditions for pain recording 4. train health professionals
Identify pain assessment scales to be applied at any age and to any disease
Behavioural assessment scales
An adequate assessment of pain is very important for its control and treatment. For this reason, the identification of pain assessment scales is one of the main objectives of the Bambino Gesù Children’s Hospital. Various scales have been analysed by a working group after a serious and in-depth bibliographic assessment of different methods applied in the pediatric field. Two scales have been chosen for two age groups: – FLACC (Face, Legs, Activity, Cry, Consolability) from newborn to four years of age; – FPRS (Faces Pain Rating Scale) children of four years and over. In addition to the FLACC and FPRS scales, specific scales will be used in sectors such as Intensive Care Units and operating rooms. Some scales (NIPS, PIP, CRIES) are currently in use in Neonatal Intensive Care Units; others are nearing completion.
What is a pain assessment scale? A pain assessment scale is an assessment method to help measure a patient’s pain intensity. Scales can be divided into three groups: – functional measurement scales – behavioural scales – multidimensional assessment scales.
Functional scales These tools tend to describe pain intensity by regular intervals, on a scale ranging from absence of pain to the worst pain. These scales show numbers, objects, drawings and colours; they are used to monitor different groups of patients. Our Hospital has chosen the FPRS scale (Faces Pain Rating Scale, see Figure 1). This scale may be used to judge pain intensity in children from the age of four. It explains to the child that every face is a person, ranging from a person who is happy because he does not feel pain, to a person who is tearful, because he is experiencing extreme pain.
PAEDIATRICS AND CHILD HEALTH 17:S1
Figure 1 Faces Pain Rating Scale. Face 0: complete absence of pain; Face 1: mild pain; Face 2: moderate pain; Face 3: intense pain; Face 4: unbearable pain.
S68
This is the most direct tool for judging child discomfort in particular situations connected to his disease, the environment, his relationship with his mother and our care treatments. Facial expressions, such as grimaces, represent the most common behaviour that shows a pleasant or discomfort condition. Therefore, we can understand these indirect messages of the patient’s emotional state by looking at the child. Unfortunately many variables can affect this survey, such as the observer’s cultural level or his personal evaluation or his personal experiences of pain. Crying is universally recognized as a pain indicator. It is a particular crying, different from others, that mothers can easily identify as an act of discomfort. Crying is not an easy signal for the nursing staff, since it depends on the personal relation between the child and the nurse. Moreover, it is important to consider the possibility that the child may not react to a painful stimulus by crying. Posture is an important aid to assessing the child’s behaviour towards a painful body part; he may hold the part or act as if indifferent to it. We can see whether the child is in pain and the degree of pain intensity according to the posture he adopts. Body movements can provide considerable information concerning the painful symptom, especially in children who do not speak or are not in the developed speech phase. Like adults, children try to avoid painful stimuli by moving away or drawing back. This is a very common experience for all nurses, for instance when taking a blood sample. Our Hospital has selected the FLACC scale (Face, Legs, Activity, Cry, Consolability), which can assess pain intensity in pre-school children. A score between 0 and 2 is assigned according to the child’s behaviour (Figure 2).
Multidimensional assessment scales In comparison with other pain assessment scales, multidimensional measurements provide more objective evaluations as they take into account both behavioural and physiological parameters. The parameters under consideration should be easy to record and should not cause any discomfort (e.g. sphygmoma-
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN PAIN MANAGEMENT
Figure 2 The FLACC scale (Face, Legs, Activity, Cry, Consolability).
CRIES (Crying, Requires increased O2 administration, Increased vital signs, Expression, Sleepless) scale created by Krechel in 1995 Crying Requires O2 sat > 95% Increased vital signs Expression Sleepless
0 NO NO NO NONE NO
1 High tone crying <30% ↑<20% Grimace Frequent awakening
2 Inconsolable >30% ↑>20% Grimace/Moaning State of wakefulness
Table 1
nometer cuff pressure during arterial blood pressure measurement). Less invasive parameters that can be easily recorded are: increase in cardiac rate, increase in respiratory rate, increase in perspiration and pupil dilation. These criteria can be compared with score tables. CRIES (Crying, Requires increased O2 administration, Increased vital signs, Expression, Sleepless; scale created by Krechel in 1995) is one of the scales selected for use by our neonatal intensive care unit (Table 1). This scale can assess pain intensity in newborns. It involves five variables and a score between 0 and 2 can be assigned to every variable. The highest score is 10. A score >5 is considered indicative.
our wards, and growth and improvement of our professional activities. Being able to offer a more patient-centred care depends on us. The child may go through the disease in anxiety and fear; providing a professional figure who, by means of a smile, helps him through his hospitalisation, also depends on us.
BIBLIOGRAPHY De Marinis MG, Mastroianni C, Agostino MB. Scale di controllo. Roma: L’infermiere, Aggiornamenti professionali, settembre/ottobre 2000. Agostino Bengtsson M. Conoscerlo per capirlo. Roma: L’infermiere, Aggiornamenti professionali, settembre/ottobre 2000. De Francisci G, Iacobucci T, Arlotta G, Mastroluca A, Cittadino M, Lauretta A, Leoni F. Il dolore postoperatorio nel bambino. Roma: Edizioni universitarie romane, 2000. Marc Schwob. Il Dolore. Milano: il Saggiatore, 1997. De Nicola A. Misurazione del dolore. Medicina in rete, 1996–2000. Prandi C. Gli strumenti di misura. Roma: L’infermiere, Aggiornamenti professionali, settembre/ottobre 2000. Boccardi G. La malattia, la separazione, il dolore mentale. Da: Bambini in ospedale, novembre/dicembre 1989. Allegro A. Il dolore e il bambino. Rimini: Dolore assistenza benessere,
Conclusion Understanding the problems and the development of joint strategies to deal with them, with guidelines and codes of conduct, will make hospitalisation and nursing care less traumatic. This is an objective that cannot be abandoned if we want to improve pediatric care. The “pain-free hospital” project presents a great opportunity for a cultural change in
PAEDIATRICS AND CHILD HEALTH 17:S1
S69
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN PAIN MANAGEMENT
Napoli: Liguori editore, 1992. Marlow DR. Trattato d’assistenza pediatrica. Padova: Piccin, 1986. De Rosa E. La consulenza psichiatrica al bambino ospedalizzato. Roma: Ente italiano di servizio sociale, 1998. Cologna M, Sperandio L. L’efficacia di due diversi presidi per il controllo del dolore da puntura del tallone nel neonato pretermine. Da: Assistenza infermieristica e ricerca, volume 18, N° 4, ottobre/ dicembre 1999. Peyron L, Bona G, Grazia G, Miniero R, Vair R. Pediatria pratica. Torino: Edizione Minerva Medica, VI edizione 1995. Ugazio AG, Bracchi G, Notarangelo LD, Candotti F. Il bambino salute e malattia. Milano: Edizione Sorbona, 1993.
N° 1, 1993. Merkel S, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs; 1997;23:293–297. Manworren RCB, Hynan LS. Clinical validation of FLACC: Preverbal Patient Pain Scale. Pediatr Nurs 2003;29:140–146. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale in acute pain for use in the emergency department. Acad Emerg Med 2003;10:390–392. Paice JA, Cohen FL. Validity of a verbal administered numerical rating scale to measure cancer pain intensity. Cancer Nurs 1997;20:88–93. Datington T, Menzies L, Williams Polacco G. Bambini in ospedale.
PAEDIATRICS AND CHILD HEALTH 17:S1
S70
© 2007 Elsevier Ltd. All rights reserved.
Pain management in pediatrics – the OPBG experience
Towards a pain-free hospital During the 1950s, first “pain-free” hospitals were set up in the USA. An innovative project was started in 1992 at the St. Luc Hospital in Montreal (Canada) with the aim of changing the behaviour of both healthcare workers and hospitalised patients (Besner 1993). Gradually, similar projects were set up in several European countries, Italy amongst them, and were soon officially recognized by the World Health Organisation. In September 2000, the Italian Ministry of Health instituted a “Pain-free hospital” study group to develop a specific project involving 20 Italian hospitals. The final guidelines were published in the Italian Official Gazette in June 2001. This project included a survey on pain management which showed that pain assessment and management in the institutions studied were far from optimal. Today, very varied approaches coexist in Italy, even if the concept of a pain-free hospital is gradually gaining ground Positive examples are the hospitals in the region of Emilia-Romagna, where the local Health Service has devised plans of action to fight pain both in hospital and at home, under the “pain-free hospital” project ratified in accordance with the State-Regional Conference held on May 24th 2001. The core of the project is the creation of “pain-free hospital” Boards, that guarantee a specific observatory of pain, coordinating and training health professionals, and promoting the establishment of protocols on pain treatment, with the aim of improving care of patients affected by pain of any origin. Currently, all the local health authorities in the region of Emilia-Romagna have instituted a “pain-free hospital” Board and have recruited more than 250 health workers of different specializations. The nursing staff involved in pain management represent more than 35% of all pain-free hospital board personnel. Moreover, many officially approved private hospitals have joined the project and established their own boards. Voluntary organizations may also join the boards.
Gaetano Ciliento
Abstract Introduction: Sometimes it is not the disease from which the child is suffering that is the main source of pain but rather our diagnostic and care procedures. In fact, nursing care as well as surgical and pharmacological treatment may produce not only physical pain but also mental discomfort; this mental discomfort can be sometimes a poor or a lack of pain assessment and control. Objective: This article remarks on the “Pain-free hospital” international project and explains the process of starting up and adherence of our Hospital, aiming at illustrating chosen strategies and tools for pain assessment and control. Conclusion: We discuss some considerations to underline how common strategies for guidelines creation can make hospitalisation and nursing medical care as less traumatic as possible for the child.
Keywords pain; assessment; scale; child; nursing care
Introduction Until only a few years ago, it was believed that a young child could not feel pain, that it would have no harmful effect on him, and that he would not remember it. Today we know that, starting at the end of the second trimester, the fetus can feel pain, while a six month-old child tries to avoid any action that could make him experience pain. The child may feel pain as an aggression; he feels threatened, punished, persecuted, in danger. Sometimes it is not the disease from which the child is suffering that is the main source of pain but rather our diagnostic and care procedures. In fact, nursing care as well as surgical and pharmacological treatment may produce not only physical pain but also mental discomfort. We should not forget that many of these children do not give their consent, feel abandoned by the people they love, and find themselves in an alien environment, surrounded by strangers who may sometimes play with them but who may also sometimes hurt them.
What is a “pain-free hospital”? A “pain-free hospital” is one which performs pain assessment and pain therapeutic control for every patient, for both acute and chronic pain. The international “pain-free hospital” project is based on the following principles: – Pain is a cross-sectional issue, common to every specialization. – The campaign should involve the entire hospital. – The hospital should relieve all types of pain. – Involvement in the campaign of the entire population is essential. The Bambino Gesù Children’s Hospital is totally committed to the “pain-free hospital” project. In fact, the Charter for children’s rights states: “Children shall have the right to undergo the least invasive and painful diagnostic and therapeutic procedures” “All staff members provide human support to the child and his/her family to prevent the onset of pain, reduce its perception, and avoid fear, anxiety and stress.”
Gaetano Ciliento is at the Healthcare Department, Bambino Gesù Children’s Hospital, Scientific Institute (IRCCS), Rome, Italy. Conflict of interest: none declared
PAEDIATRICS AND CHILD HEALTH 17:S1
S67
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN PAIN MANAGEMENT
In compliance with these principles, the Bambino Gesù Children’s Hospital has involved human and financial resources in order to develop this project in the shortest time possible. At present, a multidisciplinary group is working on a policy of action against pain by the implementation of the best strategies and using the best tools and therapeutic protocols that the scientific community can provide. The group’s work has enabled us to: 1. identify pain assessment scales that can be applied at any age and to any disease 2. assess adequate graphic documentation for pain symptom 3. set times and conditions for pain recording 4. train health professionals
Identify pain assessment scales to be applied at any age and to any disease
Behavioural assessment scales
An adequate assessment of pain is very important for its control and treatment. For this reason, the identification of pain assessment scales is one of the main objectives of the Bambino Gesù Children’s Hospital. Various scales have been analysed by a working group after a serious and in-depth bibliographic assessment of different methods applied in the pediatric field. Two scales have been chosen for two age groups: – FLACC (Face, Legs, Activity, Cry, Consolability) from newborn to four years of age; – FPRS (Faces Pain Rating Scale) children of four years and over. In addition to the FLACC and FPRS scales, specific scales will be used in sectors such as Intensive Care Units and operating rooms. Some scales (NIPS, PIP, CRIES) are currently in use in Neonatal Intensive Care Units; others are nearing completion.
What is a pain assessment scale? A pain assessment scale is an assessment method to help measure a patient’s pain intensity. Scales can be divided into three groups: – functional measurement scales – behavioural scales – multidimensional assessment scales.
Functional scales These tools tend to describe pain intensity by regular intervals, on a scale ranging from absence of pain to the worst pain. These scales show numbers, objects, drawings and colours; they are used to monitor different groups of patients. Our Hospital has chosen the FPRS scale (Faces Pain Rating Scale, see Figure 1). This scale may be used to judge pain intensity in children from the age of four. It explains to the child that every face is a person, ranging from a person who is happy because he does not feel pain, to a person who is tearful, because he is experiencing extreme pain.
PAEDIATRICS AND CHILD HEALTH 17:S1
Figure 1 Faces Pain Rating Scale. Face 0: complete absence of pain; Face 1: mild pain; Face 2: moderate pain; Face 3: intense pain; Face 4: unbearable pain.
S68
This is the most direct tool for judging child discomfort in particular situations connected to his disease, the environment, his relationship with his mother and our care treatments. Facial expressions, such as grimaces, represent the most common behaviour that shows a pleasant or discomfort condition. Therefore, we can understand these indirect messages of the patient’s emotional state by looking at the child. Unfortunately many variables can affect this survey, such as the observer’s cultural level or his personal evaluation or his personal experiences of pain. Crying is universally recognized as a pain indicator. It is a particular crying, different from others, that mothers can easily identify as an act of discomfort. Crying is not an easy signal for the nursing staff, since it depends on the personal relation between the child and the nurse. Moreover, it is important to consider the possibility that the child may not react to a painful stimulus by crying. Posture is an important aid to assessing the child’s behaviour towards a painful body part; he may hold the part or act as if indifferent to it. We can see whether the child is in pain and the degree of pain intensity according to the posture he adopts. Body movements can provide considerable information concerning the painful symptom, especially in children who do not speak or are not in the developed speech phase. Like adults, children try to avoid painful stimuli by moving away or drawing back. This is a very common experience for all nurses, for instance when taking a blood sample. Our Hospital has selected the FLACC scale (Face, Legs, Activity, Cry, Consolability), which can assess pain intensity in pre-school children. A score between 0 and 2 is assigned according to the child’s behaviour (Figure 2).
Multidimensional assessment scales In comparison with other pain assessment scales, multidimensional measurements provide more objective evaluations as they take into account both behavioural and physiological parameters. The parameters under consideration should be easy to record and should not cause any discomfort (e.g. sphygmoma-
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN PAIN MANAGEMENT
Figure 2 The FLACC scale (Face, Legs, Activity, Cry, Consolability).
CRIES (Crying, Requires increased O2 administration, Increased vital signs, Expression, Sleepless) scale created by Krechel in 1995 Crying Requires O2 sat > 95% Increased vital signs Expression Sleepless
0 NO NO NO NONE NO
1 High tone crying <30% ↑<20% Grimace Frequent awakening
2 Inconsolable >30% ↑>20% Grimace/Moaning State of wakefulness
Table 1
nometer cuff pressure during arterial blood pressure measurement). Less invasive parameters that can be easily recorded are: increase in cardiac rate, increase in respiratory rate, increase in perspiration and pupil dilation. These criteria can be compared with score tables. CRIES (Crying, Requires increased O2 administration, Increased vital signs, Expression, Sleepless; scale created by Krechel in 1995) is one of the scales selected for use by our neonatal intensive care unit (Table 1). This scale can assess pain intensity in newborns. It involves five variables and a score between 0 and 2 can be assigned to every variable. The highest score is 10. A score >5 is considered indicative.
our wards, and growth and improvement of our professional activities. Being able to offer a more patient-centred care depends on us. The child may go through the disease in anxiety and fear; providing a professional figure who, by means of a smile, helps him through his hospitalisation, also depends on us.
BIBLIOGRAPHY De Marinis MG, Mastroianni C, Agostino MB. Scale di controllo. Roma: L’infermiere, Aggiornamenti professionali, settembre/ottobre 2000. Agostino Bengtsson M. Conoscerlo per capirlo. Roma: L’infermiere, Aggiornamenti professionali, settembre/ottobre 2000. De Francisci G, Iacobucci T, Arlotta G, Mastroluca A, Cittadino M, Lauretta A, Leoni F. Il dolore postoperatorio nel bambino. Roma: Edizioni universitarie romane, 2000. Marc Schwob. Il Dolore. Milano: il Saggiatore, 1997. De Nicola A. Misurazione del dolore. Medicina in rete, 1996–2000. Prandi C. Gli strumenti di misura. Roma: L’infermiere, Aggiornamenti professionali, settembre/ottobre 2000. Boccardi G. La malattia, la separazione, il dolore mentale. Da: Bambini in ospedale, novembre/dicembre 1989. Allegro A. Il dolore e il bambino. Rimini: Dolore assistenza benessere,
Conclusion Understanding the problems and the development of joint strategies to deal with them, with guidelines and codes of conduct, will make hospitalisation and nursing care less traumatic. This is an objective that cannot be abandoned if we want to improve pediatric care. The “pain-free hospital” project presents a great opportunity for a cultural change in
PAEDIATRICS AND CHILD HEALTH 17:S1
S69
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN PAIN MANAGEMENT
Napoli: Liguori editore, 1992. Marlow DR. Trattato d’assistenza pediatrica. Padova: Piccin, 1986. De Rosa E. La consulenza psichiatrica al bambino ospedalizzato. Roma: Ente italiano di servizio sociale, 1998. Cologna M, Sperandio L. L’efficacia di due diversi presidi per il controllo del dolore da puntura del tallone nel neonato pretermine. Da: Assistenza infermieristica e ricerca, volume 18, N° 4, ottobre/ dicembre 1999. Peyron L, Bona G, Grazia G, Miniero R, Vair R. Pediatria pratica. Torino: Edizione Minerva Medica, VI edizione 1995. Ugazio AG, Bracchi G, Notarangelo LD, Candotti F. Il bambino salute e malattia. Milano: Edizione Sorbona, 1993.
N° 1, 1993. Merkel S, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs; 1997;23:293–297. Manworren RCB, Hynan LS. Clinical validation of FLACC: Preverbal Patient Pain Scale. Pediatr Nurs 2003;29:140–146. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale in acute pain for use in the emergency department. Acad Emerg Med 2003;10:390–392. Paice JA, Cohen FL. Validity of a verbal administered numerical rating scale to measure cancer pain intensity. Cancer Nurs 1997;20:88–93. Datington T, Menzies L, Williams Polacco G. Bambini in ospedale.
PAEDIATRICS AND CHILD HEALTH 17:S1
S70
© 2007 Elsevier Ltd. All rights reserved.