Addressing Pain Management Strategies in an Outpatient Pediatric Practice for High-needs Patients

Background: To address pain management in a busy pediatric outpatient practice for high-need children and to understand barriers to implementing evidence-based pain management strategies.

Methods: We combined a quality improvement initiative with a mixed-methods evaluation of medical staff in a large, urban pediatric medical home to 1) assess practice of pain management strategies using surveys completed before and after a short training session on pain management; 2) examine attitudes toward pain management and barriers to trauma-informed care by conducting in-depth interviews with providers and staff; and 3) generate ideas for how to implement pain management into busy clinical practice flow. We provided training sessions to an entire safety net practice, including nurses and providers, regarding trauma informed care and the use of strategies to help alleviate inflicted pain. Strategies included: 1) intentional language and word choice when discussing vaccine delivery and blood draws; 2) demonstration of proper positioning techniques; and 3) and use of distraction techniques incorporating I Spy books ™ and Buzzy Bee ™, a vibrating plastic instrument applied with an ice pack to the skin. 1) Survey data were analyzed using descriptive statistics and bivariate analysis. For inductive analysis of interviews, three investigators independently coded for themes. A fourth coder resolved differences and performed member-checks.

Results: Among the 31 survey respondents (response rate: 71% of attendings, 100% of nurse practitioners), there was an increase in report of using pain management strategies from 30 % (pre training) to 100% (post training) (P < 0.005). Following the training, the majority (85%) of providers reported they had used the new nursing communications for Buzzy Bee™ during visits, especially for children 3-5 years old. The in-depth interviews with providers, nurses, and technicians (n=13) revealed three major themes (Fig 1): 1) need for a trauma-informed care approach regarding pain management, particularly for vulnerable populations of children; 2) time as a major barrier, and 3) setting realistic goals and expectations for clinical roles in practice and the need for efficient strategies. Providers suggested ways to improve pain management, including simple educational material for parents, revisions to the nursing communication order set to include pain management for immunizations, and mindful attention to words used to describe pain and painful procedures.

Conclusion: In a busy clinical setting, providers and staff can benefit from education on pain management in the context of providing trauma-informed care.