Pediatric pain practices: A national survey of health professionals

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Pediatric Pain Practices: A National Survey of Health Professionals Marion E. Broome, PhD, RN, FAAN, Anthony Bichumeier, MD; Virginia MaikJer, PhD, RN; and MaryAnn Alexander, RN, MS School of Nuking (M.B.), Uniq of W&rain-Mihuauhe and The Chi&enS Haspikd OJ Wiscm’n, Mikauke, Wisconsin; Lkfmtmmr of Pediahics (A. R), Cal&ge OJ Medic-me> Rush Uniwnity; fkplmenl o/MatemaKhild Nursing (L!M.), Rush University; and CdLgc of Nursing (MA.) and Drpmhenl OJ Orthwics (M.A.), Rush Uniwnify, Chicago, Illinois

Tk purpace o/Uris study was to examine how heallhzare pmuidm in U.S. leaching ho.@als asses and manage children’s pain. A SPi&m questionnaire was senl to institutions with ppdiohic r&&nq programs listi in the 1992 National R&iency Malching earn. Two hundred and hoentyseuen queslionnaiws were senl and I13 mere returnad Ti~&inis u.weJmm nurses, one-third from physicians. Sixty percent oJtk nspondmlrsrared~IhyhodslolldonLro/Eclrem~~Jmpaininlheir in.rtiWioms, but only oae-quarler repmled lhol Ihe sl~ndam!r were Jobwed 80% or mow oJ the lime Use OJJmmal pain-menl tooLs was npmtad by 73 % OJ tk sample, Re+nde&@nedthattkeJj&.wu of pain asesmcnt and manognnenr was lower Jim in/an& and ymcngm children. Only 35 % o/ti sample i&cated in was “Uely ‘* or “very likely” thal pawn& would be in&d in pIann@ prior io a painful event. Several cMacks to a&qude pain management were identifinl 4 tk responabtis: knowklge d&ii, &tit&, and rwn~nes. J Pain Symptom Manage 19%;11:312-320.

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atric professionals about the need for adequate assessment and management skills to provide QpGmaJ care for hospiralized children. A variety of texts, symposia, and consensus panels, and volumes of research have been devoted to me subject of pedianic pain over the last 15 years.‘-’ Yet, many health professionals still report that adequate pain assessment of children remains inconsistent and that the effective management of pain in infants, children, and adolescents is sporadic. Attitudinal studies of health professionals over the past 15 years have documented the w385-3924/96/$15.00 !iSDlo8853924(95)oo2o57

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persistence of misconceptions about children’s ability to perceive pain and the need for aggressive management.‘*’ One survey of pain conducted in 1992 revealed that 87% of children still reported unrelieved pain during hospitalization.’ In two very recent studies of actual pain practices in pediatrics, both prescribed and administered dosages for opioid analgesics were lower than rec0mmended.s” Roth of these studies were restricted to single institutions in different regions of the country. Hence, in spite of the increased attention given to studying pediitric pain, there remains a need for a better understanding about if, and how, published research has influenced the reported practices of health professionals related to the assessment and management of pain in children. The purpose of this study was to document the perceptions of healthcare providem across the country about practices in their teaching hospitals related to the assessment and management of pain in cbiidren. No such survey has been published. This study is the precursor to kuger muhiple-site studies of observed practices of healthcare prmiden. The authots believed data from such a study would provide a better undemanding of the factors that stih influence our ability to achieve optimal pain management for children and would provide guidance for more comprehensive e&xation progtauls. The questions that guided this study and construction of the survey were the following: 1. Is education related to pain included in basic educational programs in medicine and nuning? 2. To what extent have pain standards been developed and to what extent are they used in U.S. teaching hospitals? S. What pain assessment strategies are reported to be used by heahhcare protiden? 4. What pharmacologic and nonpharmaco logic pain management interventions are reportedly used to relieve children’s pain? 5. How well do clinicians think pain in chiidren is assessed and managed in their institution? 6. How many institutions utilize a pain vice and what is the scope of practice this service?

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The study was approved by the Human Investigation Committee at the investigaton’ institution. The 212 hospitals with pediatric residency training programs in the National Resident Matching Medical Program Directory, 1992-1993 Positions’ were selected for inclusion in the study. These hospitals included those serving both adults and children, as well as children’s hospitals. They were selected because they are likely to provide care for acutely and chronically iU children who experience significant pain, and could be *.xpected to have physicians and nutses who are relatively cognizant of the pain assessment and management literature. The unit manager of a general service pediatric unit at each institution was called and asked to provide the name of one nu13e and/or physician in the institution who was most knowledgeable about the pain assessment and management pt-actices in pediatrics at that institution. One hundred and fifty of the 212 institutions provided at least one name, while the othen suggested sending the questionnaire to *he chairman of pediatrics or anestbesidogy, or tbe director of nursing. A total of 227 questionnaires were sent One hundred and thirteen were returned. for a 59% response me. In seven of the institutions, both individuals wbo were sent tbe questionnaires returned them. Twothitds of the respondents were ntttses and onetltird were physicians. Fiftysix percent of those returning the surveys indicated they wem most closely al?Jiated with general pediatrics; others were affiliated with oncology (17%). pediauic sumties (15%) such as emergency room (RR), critical cane, and surgety. or anesthesia (12%). Sewmty-two percenthadaspecialintercstandexpertiseinpediatric pain managemen& spending an average of 29% of their time on pain-related clinical act&+ ties, 1% on pain education, and 7% on painrelated research. MdattUt?lMtl

The survey questionnaire was developed bj five members of a pediatric pain team, based on their ex+ence and discussions with coUeagues. Several initial drafts wet-e piloted using individuals within the autbon’ instiNtion. The quesdon-

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&re consisted of a total of 59 questions orga&ed within live categories. The fk Qtegories were (a) gain standards and education; (b) pain assessment strategies; (C) options for pharlMCOlogic and nonpharmacologic managemenu (d) vnt of severe, ongoing pain; and (e) udliration of a pain service. Respondents were provided with several options for each question. The response format varied depending on the intent of the question. For some questions, frequency responses were supplied (i.e., often-never); while in others, respondents used a IO-point rating scale (i.e., 1 = not well managed; 10 = very well managed). For severai questions respondents were provided a list of options, such as nine nonpharmacologic strategies. and asked to indicate how often the strategy was employed in their institution. Appendix 1 includes a list of 10 representative questions from several sections of the survey.

The choice of data analyzed tiom this stuc’y and chosen to present in this paper was based on the research questions used to guide the development of the questionnaire. Fwres are used to highlight information thought to be of interest to the widest variety of readers, and which did not duplicate the discussion in the WXL

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andI?G-iUUltiLmA&oUlPti Over 60% of the institutions stated they had standards of care or protocols for pain management Forty percent of the respondents indicated the standards were followed more than 50% of the time. Seventy-three percent (N = 56) of the 77 nurses who completed the questionnaires indicated that education related to pain assessment and management wds included in the nursing school cur&ubun. while 7 (9%) did not answer the ques tion. Only 17% (N = 6) of the 36 physicians who answered the question indicated the medical curriculum contained such content, with 15 (42%) choosing not to answer this question. Ye& when physicians were asked whether pain assessment and management content wre induded in the residency program, 69% (N= 25) indicated i; was. Only 4

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individual physicians chose not to answer this question. Forty percent of the overall sample indicated that pediitric pain management was a part of the institution’s quality assurance activity. When asked what they saw as obstacles to optimal pain management in their setting, 83% indicated knowledge deficits, 77% cited attitudes, 35% stated skills. and 36% identified a lack of resources. Only 4% ojlfre m+ndmLs

indicated them wen no obstachsto ofheat pin numqement in their instifudmr. Assessment of Pain Respondents were asked to provide information about what specific assessment 1~1s they used to assess children’s pain. Twenty+even percent reported they used no formal sehreport scales. while 73% reported using at least one, and usually several, self-report scales. Behavioral assessment scales were used much less commonly. Only ‘20% of the sample reported using behavioral observation scales as an assessment strategy in their institution. When asked to indicate “How effectively is pa+ assessed at your institution” on a scale of 1 (not well aueaed) to 10 (very well amessed), the respondents indicated that the younger the child, the less effective they believed the assessment to be (Figure 1). The median score for as-ament effectiveness for neonates/ infants = 4.0, toddlen/preschoolen = 6.0, and school-age children/adolescents = 8.0. These ratings of the effectiveness of assessment across age groups are significantly dirferent Respondents rated the assessment of schoolage children and adolescents as significantly more effective than assessment of pain of

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neonates/infants (Z = -8.32, P = O.OOOl) and toddler/preschoolen (Z = -8.14; P = 0.0001) and toddlers/preschoolers as significantly more effective than neonates and toddlers (Z = -7.07; P= 0.6901).

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Managemenf of Pain Respondents were asked to indicate which of 14 pharmacologic and 9 nonpharmacologic treatments were used in the management of pediatric pain in their institution. Systemic opioids were reported as used “often” by 66.4% of those surveyed, while 26.5% chose “sometimes.” Sbt percent indicated systemic opioids were “rarely” used. Nonsteroidal antiinflammatory drugs, in general, were used much less frequently; however, acetaminophen was used “often” (92%) or *‘sometimes”(7%) by the overwhelming majority of the respondents. Adjuvants, such as antidepressants or anticonvulsants, were also reported as being used infrequently by almost l/2 the respondents. In contrasg benzodiaaepines were reported being used “often” and “sometimes” by over one-half of the sample. Over 50% of the respondents reported using a meperidinechlorpromazine-promethazine combination (the “DPT cocktail”) “often” or “sometimes.” Placebos were “never” (58%) to “rarely” (36%) used to manage children’s pain. The most commonly administered regional anesthesia was epidural. with over one-half of the sample reporting use ‘*sometimes” or “often.” Caudals were reported used “often” or “sometimes” 31% of the time. Peripheral nerve blocks and inttathecal anesthesia were both reported as “rarely” to “never” used by over one-half (60%) of the sample. When respondents were asked whether opioids were used in combination with other drugs for children in moderate to severe pain, only 15% said it vms “very likely,” while 56% indicated it was “likely” Respondents identified the most commonly used routes of administration for opioids. The most common route used was intravenous, followed by oral and then epidural. lnttamuscular injections were still used “sometimes” to “often” by 48% of the respondents, even in some cases for children with intravenous access. A variety of other routes are used occasionally, including ttansdermal. rectal, and intrathecal routes.

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Scheduling of opioids varied considerably, with all institutions reportedly using a variety of options. For instance, while over 60% indicated they used “as needed dosing” (the PRN “sometimes” to “often.” 63% also system) stated they used both continuous infusion and patienttontrolled analgesia (PCA) “often” to “sometimes.” The age of children using PCA ranged from 1 to 16 years of age, with a mean of 6.2 years. Eighty-five percent indicated the standard lower age limit for PCA use in their institution was 5 years or older. Nonpharmacologic techniques, such as relaxation, distraction, imagery, positioning, and massage were all reported as ttred “often” or “sometimes” by over 56% of the sample. Other techniques, such as behavioral therapy (35%). thermal modalities (33%). uanscutaneous electrical nerve stimulation (TENS) (18%). and hypnosis (18%) were repnrted as being administered “sometimes.” Over onehalf of the sample indicated that it was unlikely that chit-en would meive pro& sional assistance with nonpharmacologic pain management techniques. When asked how informed and invdvcd they believed the families to be prior to an anticipated event musing pain, only 55% indicated it was “likely” or “very likely” to occur. When the respondents were asked how well they believed pediatric pain was managed in their instiNtion. the same pattern emerged as was found for the assessment practices (see Qure 2). When asked to indicate “How efTectivety is pain managed at your instiNtion” on a scale of 1 (not well managed) to IO (very well managed), the respondents indicted that the younger the child, the less effective they

believed the management t9 be. The median score for management effectiveness for neonates/infants = 4.0; toddlers/preschoolers = 5.5 and school-age children/adolescents = 7.5. Once again, respondents rated the overall effectiveness of pain management as significandy different across age groups. The pain of schooisge children/adolescent children was rated as significantly better than toddler/ P = 0.0001) and preschoolers (2 = -7.09, neonate/infants (2 = -8.18; P = 0.0001). and toddlers/preschooler were rated as better than neonates/infants (Z= -7.07; P= 0.0061).

Maw of children with Severe, Ongoing Pain Respondents were asked a series of ques tions about the management of children in their institution who were experiencing severe, ongoing pain. Almost 90% of the sample indicated that these children were likely or very likely to receive intravenous opioid analgesics, and 57% indicated nono pioid analgesics would also be used, if nccessary. Forty-five percent indicated that PCA with continuous infusion and PRN boluses (60%) would be used to administer the analgesic. intramuscular injections were used rarely, with 16% reporting occasional use. Only 20% of the sample reported that a pain service was likely to treat these children, with even fewer (16%) indicating it “t:kely” or “very likely” that these children would receive professional assistance with nonpharmacologic pain-management techniques.

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Seventy-two percent of the respondents indicated they were not aware of any serious sequelae resulting from pain treatment at their institution. The 27% who reported complications included 38 specific incidents that ranged from “aspiration” to “respiratory arrest.” The overwhelming majority were related to oversedation and respiratory depression. Eleven of these complications were associated with the adminisuation of morphine, five with the “DPT cocktail,” and one with methadone. Other aequelae noted included seizures and allergic reactions.

PainseruicpJ Thirty-five percent of the institutions identified themselves as having a pain service. How-

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ever, pain consultation was available in 53% of the responding institutions, provided by a variety of he&h-care providers from anesthesia, psychiatry, nursing, and pediatrics. The over, whelming majority of the pain services were anesthesia-based units. The focus of the pain services included management of both acute and chronic pain, with consultation available 24 hr a day in 75% of the institutions with a pain service. The majority of the children seen by pain services were surgical cases (65%). Sixty-one percent of the pain services’ activities were jndged to be related to managing already existing pain. Only 25% dealt with pain prevention. Fifty percent of pain services participated in preoperative planning. Neonates were rarely seen by pain services, while the percentages of children seen by the services increased with the age of the children. There ‘!ere no significant differences in the perceived effectiveness ratings for pain assessment between institutions with and without pain services for any of the three age groups [neonates/infants (U = 1014.0; P = 0.84); toddlen/preschoolen (U = 1397.5; P = 0.88); school-age children/adolescent (U = 1294.0; P

= 0.43). There was also no difference in how respondents’ rated the effectiveness of pain management for neonates/infants (U = 947.5; P = 0.24). However, there were significant favorable differences in those institutions with pain services in how effective the respondents thought the pain was managed for toddlers/ preschoolers (Z = 1001.5; P = 0.03) and school-age children/adolescent (U= 973.0; P= 0.007) groups.

The results of this national survey are consistent with what most experts in pediatric pain have anecdotalty reported at conferences and in clinical discussions in the literature, as well as recent reports of actual practices reported in the litetature.s.c Twenty-seven percent of the respondents indicated they do not use any self-report pain assessment scales, while over 96% reported major obstacles IO optimal pain management in their institutiof.3. Yet, multiple scales for children ages 4-18 years are available and have demonstrated adequate reliability and salidity’S This

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lack of attention to pain assessment seems to be related more to inadequate appiication of what is known about pediatric pain, rather than to a deficient knowledge base. These findings suggest that although there is much we can still learn about children’s responses to pain and the interventions we provide, the major challenge of the next decade till be to make what is known accessible to, and utilized by, health providers. More emphasis needs to be placed on educating medical and nursing students about pain assessment and management Core curricula are available, for both undergraduate and graduate education, as well as postgraduate training for residents and nutses.* As more h-dpitals target pain as a quality indicator, the clinical training emphasis will change. Class room learning is not 3tfficient to increase knowledge and confidence, so that additional learning opportunities will be needed, such as journal clubs, pain seminars, bedside teaching rounds, gtand rounds, and modeling by experienced physicians and nurses. Pain assessment for nonverbal and preverbal children remains an important clinical and research challenge. There are a variety of behavioral observation scales available.’ With the exception of the CHEOPSs and TPPPS, most were developed to observe behaviors of children during painful procedures and tested with opulations of chronically ill children.’ !i J’ These may or may not be suitable for children in acute care settings. Although self-report is the assessment parameter of choice, there are populations of pediatric patients who are not able to provide a selfassessment of their pain, such as infants and other preverbal children, those on ventilatory systems, and some vho are developmentally disabled, and their pain must be inferred in other ways. Clinicians who answered this survey reported lower tat@ of effectiveness for pain assessment and management in younger children, and it is incumbent upon pain researchers to continue to develop and test assessment scales for use in the clinical arena. Data froin thii survey related to pharmaco logic management are somewhat inconsistent with recent guidelines. Some progress has been made when compared to earlier clinical reports in the literature. as reflected by the reports of decreased use of placebos, and an

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apparent Increase in the use of PCA and continuous infusions. The age range of children receiving PCA varied considerably. The reported mean age of 6.2 years for was somewhat suprising. This is most likely a result of the acronym “PCA” being used to describe parentcontro!led and nutse-controlled infusions, as well as those actually controlled by the child. The continued use of IM injections for managing pain is unwarranted given the variety of alternative routes that have been demonstrated to be more effective. The widespread use of acetaminophen and somewhat limited use of more efficacious therapies suggest that acetaminophen is frequently being used alone for pain reported 5y children during hospitalization. Whether this widespread usage is appropriate requires further study. However, this practice is not reflective of newer, recommended pharmacologic regimens for moderate to severe pain.‘~‘2-‘5 This survey, as well as othen.5” indicate that children are still not receiving adequate dosages of analgesics for their pain. This survey did not provide information about wby some of these practices remain and future inquiry needs to be focused in this area. Nonpharmacologic techniques were used by one-half of the sample, but many stated it was unlikely that children and parents would receive instruction in using the techniques. There is initial evidence for the efficacy of these techniques, and they should be encouraged. Ho-r, most families will need instruction and assistance in use of the techniques for maximal beneliL’6 The involvement of parents in assessment and management of their children’s pain is one area in which practice lags far behind recommendations from experts.’ Ambiguous pain cues from children are more likely to be interpreted correcdy b parents, especially those of preverbal children. Parents can be a primary source of support for children undergoing painful procedures and should be involved in every f&et of their children’s pain management plans-from the initial interview through discharge planning. Data from this survey support the previous findings that the management of pain can be improved by collaborative efforts of multidisciplinary pain teams in some inuituti0ns.“-‘” Interestingly, pain services appear to have had no beneficial effect on the management of

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pain in neonates and infants. This is most likely due to the fact that this age group is least likely to be seen by pain services. However, dte fact that there was a significant difference in the perceived effectiveness of pain assessment and management in institutions with a pain service suggests that these multidisciplinary efforts are at least somewhat effective in enhancing pain control for children. More research will be needed to determine what aspects of multidisciplinary efforts contribute to improving pain control.

Limitalti Pain practices reported in this survey were self-reports based on a 50% return rate and could be subject to selection bias or reports of exaggeration in either direction, depending on what effect the respondent hoptd the results would have. Responses to mailed questionnaires are generally poor, with returns of 25%-46% common. ae Bias from a homogeneous sample, such as that in this study, has been found to be less of a threat to generalizabilitys’ witbin that specific population (i.e., teaching hospitals). A limitation of this study, however, is the inability to generalize the findings to other training programs. smaller hospitals, or community-based hospitals. Although it seems unlikely that pain practices in these other institutions would be more progressive, an empirical analysis is warranted before assumptions are made. For the sample of teaching h~pitals in tbis study, it appears that although there has been some improvement in the use of assessment tools and a variety of pharmacologic options, there is still much to be done to change professional practice to be more reflective of current recommendations on pediatric pain. There is a crucial need to examine, through observation and chart reviews, actual practices of health professionals. However, many of the respondents wrote several descriptive comments on their surveys and seemed very open and candid about their thoughts and ptacticcs related to children in pain. Future research efforts should also roncentrate on the development and testing of educational programs to improve the knowledge and skill base of physicians and nurses, on dissemination sttategies to get the latest research to those at the bedsiie. and on the development aud testing

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of observational scales to assess children’s pain better. There is a great deal of work still left to be done to achieve optimal management of children’s pain. With only 4% of respondents indicating they thought there were no obstacles to optimal pain management, it is clear that one of the major challenges of the next decade will be to improve the utilizrtion of research and application of knowledge by physicians and nurses directly caring for children in pain. Improving utilization of the current knowledge base will require clinicians and researchen to work witb each other and parenti to develop innovative programs to address the needs of children in pain. It is only through all health professionals working collaboratively with each other and with families that children will receive optimal pain management.

1. U.S. Department of Health and Human Services. Quick reference guide for clinicians. Acute pain management in infants, children and adolescents: operative and medical procedures. Agency for Health Care Policy and Research (AHCPR) publication no. 926020. Rockville. MD: AHCPR. Public Health Service, 1992. 2. International Association for the Study of Pain (IASP).

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S. Schechter and children.

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N, flerde C. Yaster M. Pain in 1n6mt.s Baltimore:

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and Wilkins,

1993.

4. Johnston C, Abbott F, Gay-Donald L, Jeans M. A %wzey of pain in hospitalied patients aged 4-14 years. Clin J Pam 19!32&164-165.

5. Tesler

M. HGlkie

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W. Save&s children

M. and

adoiescents: prescription and administration. Symptom Manage 1994;9:65-94.

J Pain

6. Altimer L. Norwood S. Dick M, Holditch-Davis D. Lawless S. Postoperative pain management in prwerbl childrxn: the prescription and adminisuation of analgesia with and without cat&l analgesia. J Pediau Nun 19943%6-232. 7. National

Evanston. Program. 8. McGath

Resident

Matching

Medical

IL National 199).

Resident

Matching

P, Jnhr.ton

J. Dunn J, Chapman

G, Goodman

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Program.

Medical

J, SchiXnger

a behavioral

scale

for rating postqxra*ive pa% in children. In: Fiel& HL Dubner R, Cervero F. eds. Advances in Pain

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research and therapy, vol 9. Proceedings of the Fourth World Congms on Pat”. New York Raven. 1985395-lO2. 9. Tarbell S, Cohen T, Marsh J. The ToddlerPreschooler Postoperadw Pam Scale: an observetimalscderor “wa?tui”g pc3st~peladve pain in chic dm” 13: preliminary report. Pat” 1~27~286. 10. Jay S. lnvasivc medical procedures: psychdogical intervention and assessntent. In: Roulh DK ed. Handbook of pediatric psychology. New York Cuilford. 1987401-425. 11. Katz E, Kellerman J. Siegel S. Behavioral distress in children with cancer undergoing medical procedures: developmental considentions. J Consult Ctin Psycho1 1986:48:556565. 12. Korcn G. Levy M. Pediatric use of opioids. I”: Blumer J, Reed M. eds. The pediatric clinics of North America: clinical pharmacology. vol 96. Philadelphia: WB Saunders. 1989:1141-I 157. IS. Maunuluela E. Non-steroidal antiin8ammatory drugs in pediatric pain ntanagement. In: Schechter N. Bet-de C. Yaster M. Pain in infants and childten. Baltimore: Williants and Wilkins, 1995:1S5-144. 14. Moncnson M, Bennebohm R Clinical pharmacology and use of non~ctGdal and-inRammatory drugs. In: Blumer J, Reed M, eds. The pediatric clinics of North America: clinical pharmacology, ~01 36. Philadelphia: WB Saunden, 1989:1113-1141. 15. Yaster M. Maxwell L. Opioid agonists and antagomsts. In: Schechter N. Berde C. Yastcr M. Pain in infants and children. Baltimore: Williams and Wilkin. 1993;145-172. 16. Broome M. Lillis P, Smith MC. Pain interventions in children: a mctaanalylis of the research. Nun Res 1989;38:154-158. 17. Alexander M. Richtsmeier A, Broome M, Barkin R A multidisciplinary approach to pediatric pain: an empirical analysis. Child Health Care 199% n:81-91. 18. Berde C. Cahill C. Multidisciplinary ptugtants for pain management. In: Schechter N. Be& C. Yaster M. eds. Pain in infants. children and Ado& cents. Baltimore: Williams and Wilkins, 1999:34% 356. 19. Shapiro B. Cohen D. Ccwelman K. How C. Scott S. Experience of an interdisciplinary pain service. Fediatrics 1991;88:1226-1232. 20. Kerlinger F. Foundations of behavioral research. New York: Hoh. Rinehart. and Winston. 1986. 21. Lcsri L. Arc high response lam cnrcntial to mlid surveys? Sot Sci Res 1972;1:!32S-34.

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Appendix1 RfjmenWive Qtmfionsfiom the Sutvq of Pediatric Pain hcticts Qupshnmire What, if atty. are obstacles to optimal pediatric pain management at your institution? (circle all that apply) a. knowledge b. skills c. reso”rccs d. attitudes e. other (specify) f. none On the same scale, in general, how e&cLively do you think pain is MANACED at your institution for the following age groups? 1 2 Not Well Managed

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Are you aware of any serious sequelac resulting from pain treatment for pediatric patients at your institution? YCS No Briefly Describe: For children receiving opioids for severe pain how likely are they to receive them in combination with other analgesics? I Very Likely

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How likely are these children to receive fesional assistance with nonpharmacological pain management techniques? 1

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What is the focus of the pain service? all that apply) adult pediatric acute pain chronic pain

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Approximarc!y what percentage of the time (per 24 hr/7 day time span) is consultation available? 25% 50% 75% 100%