Improving pain management is a priority key performance indicator on the SickKids Quality Improvement Plan. SickKids pain assessment policy mandates the use of validated pain assessment tools after all procedures, and interventions for moderate to severe pain. The purpose of this audit was to benchmark the frequency of pain score documentation with a validated tool, incidence of moderate to severe pain and pharmacological interventions for moderate to severe pain given in PACU.

Background

After approval from Quality and Risk Management (Research Ethics Board exempt), a retrospective paper-based audit was undertaken. 100 consecutive patients were identified from the operating room daily census over 4 days in July 2013; one patient did not undergo surgery as planned and was therefore excluded. Data was collected and anonymized from the charts of the remaining 99 patients excluding direct PICU/NICU admissions, non-surgical procedures (MRI, CT, endoscopy) and interventional radiological procedures.

Methods

Conclusions Documentation of pain and use of validated assessment tools was variable. Moderate to severe postsurgical pain was common (40%), however pain interventions were often given. Some patients received pain medication without pain score documentation, leading us to believe that clinical assessment for pain was done but not documented. In response, feedback reports, reminders and educational interventions were implemented and are ongoing. Targeted KT strategies improved pain assessment practices. PACU is incorporated into daily continuous improvement plan and moving forward we will focus on factors that contribute to moderate to severe pain as the

next quality improvement issue.

Figure 1 - Audit Tool

Objective

•  Assess frequency of pain score documentation using validated pain assessment tools.

•  Incidence and intervention for moderate to severe pain in PACU?

Results

Figure 2: Quality Improvement Cycle

Monitoring Tool Paper based audit tool was used to determine process outcomes and

clinical outcomes in 100 PACU admissions.

Auditors One pain fellow assigned to

complete the assessment using the monitoring tool to extract

data from patient record/chart.

Data Analysis Process outcomes (pain

assessment using validated tools, interventions for mod-

sev pain), and clinical outcomes (prevalence mod-sev pain) were quantified.

Knowledge translation (KT) Paper Feedback Report,

educational interventions and reminders regarding pain

assessment practices were implemented and ongoing.

Feedback Meetings Met with key leadership personnel in PACU and

presented the report focusing on areas of excellence and

identifying targets for improvement.

Feedback Report

Daniel Stocki MD1,2, Gail Wong MBBS FANZCA1,2 , Conor McDonnell MD MB FCARCSI1,2, Kelly Shackell RN1, Gloria Kotzer RN1, Sabrina Bhatia MBA1, Fiona Campbell MD FRCA1,2

1The Hospital For Sick Children (SickKids) Toronto, ON (Canada) 2University of Toronto, Toronto, ON (Canada)

A Quality Improvement Project for Improving Pain Outcomes in a Pediatric Post Anesthesia Care Unit (PACU)

1. Process outcomes:

Prevalence of moderate to severe pain: Prevalence: 27/68 (40%) patients had at least one moderate to severe pain intensity score. There may be many reasons for this – if your patient has moderate to severe pain please provide an intervention if possible.

PACU Quality Improvement Pain Feedback Report for Daily CIP

Inpatient(pain(satisfaction(is(a(key(performance(indicator(at(SickKids,(and(a(priority(indicator(on(the(SickKids(Quality(Improvement(Plan.((Excellence(in(PACU(pain(practices(may(have(a(positive(impact(on(inpatient(pain(satisfaction.(A(retrospective(chart(audit(of(process(&(clinical(outcomes(pertaining(to(pain(was(undertaken(in(PACU(in(July(2013;(100(patient(charts(were(included(J(1(excluded(due(to(documentation(error.(((PROCESS'OUTCOMES;'i.e.(are(we(doing(what(we(are(supposed(to(be(doing?'

1.'Pain'Assessment'

a.'Pain'assessment'documentation(

• 68/99((69%)'of(eligible(patients(had(a(pain(assessment(documented.((• 283(pain(assessments(were(documented(for(the(68(patients((average(J(4(

pain(assessments(per(patient.(✓ More(than(two(thirds(of(patients(are(having(pain(scores(documented.(

Well(done!(The(NRC(Picker(target(is(>82%.(Keep(up(the(good(work(and(remember(to(assess(pain(in(all(your(patients.(

'b.'Use'of'validated'pain'assessment'tools:'

• 23/68((34%)(had(a(pain(assessment(tool(documented,(including(use(of(nonJvalidated(tools.(

• 13/68((19%)(had(a(validated(pain(assessment(tool(documented;(NRS((3),(FLACC((6),(4JPoint(Verbal(Rating(Scale((4)((

✓ Please(remember(to(use(validated(pain(assessment(tools(–(these(can(be(found(on(the(SK(Pain(Assessment(Policy,(and(the(laminated(pain(score(badgeJcards.(

(2.''Intervention'given'for'moderate'to'severe'pain:'

• 23/27((85%)(received(an(analgesic(for(moderate(to(severe(pain.(Physical(and(psychological(interventions(were(not(documented. (

✓ The(majority(of(patients(received(a(pharmacological(intervention(for(moderate(to(severe(pain(–(well(done!(

✓ An(interesting(observation(is(that(8(patients(received(analgesics,(including(opioids,(without(a(documented(pain(assessment.(

((CLINICAL'OUTCOMES(

3)'Prevalence'of'moderate'to'severe'pain:''• Prevalence:(27/68((40%)(patients(had(at(least(one(moderate(to(severe(

pain(intensity(score.(✓ There(may(be(many(reasons(for(this(–(if(your(patient(has(moderate(to(

severe(pain(please(provide(an(intervention(if(possible.((

Inpatient pain satisfaction is a key performance indicator on the SickKids Scorecard, and a priority indicator on SickKids Quality Improvement Plan. Excellence in pain practices in PACU might be expected to have a positive impact on inpatient pain satisfaction. This retrospective chart audit of process & clinical outcomes pertaining to pain was undertaken in PACU in July 2013; 100 patient charts were included - 1 excluded due to documentation error.

Use of validated pain assessment tools: 23/68 (34%) had pain assessment tool documented, including use of non-validated tools. 13/68 (19%) had validated pain assessment tool documented.

Pain assessment documentation: 68/99 (69%) patients had a pain assessment documented. Total 283 documented pain assessments.

2. Clinical outcome results:

Intervention for moderate to severe pain: 23/27 (85%) received an analgesic for moderate to severe pain. Physical and psychological interventions not documented. 8/99 (8%) received analgesics, including opioids, without documented pain assessment.

3. Re-audit of pain assessment documentation after KT strategies:

Pain assessment documentation: The rate of pain assessment documentation improved after implementing reminders and educational interventions in October 2013. In January 2014, 100% of audited charts had documented pain scores.