pain assessment without borders - aacpdm gillette priority looking to develop a kt framework looking...

8/15/2017

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Pain Assessment Without Borders:Keeping chronic pain assessment at the forefront of

care for children with cerebral palsy

Ashleigh Townley, Chantel Barney, Jean Stout, Jean StansburySeptember 16, 2017

Objectives

• Learn about the:

– Chronic Pain Assessment Toolbox for Children with Disabilities

– Implementation of the Toolbox in a Canadian context

– Utility of a Train-the-Trainer model

– Tailoring the Toolbox to an American context

– Clinical impact of systematically assessing chronic pain

– Perspectives from front-line clinicians

• Explore how you can apply the Toolbox to your context

Evidence-informed care is anexpectation of all health care

professionals in leading academichealth sciences centres

around the world;

however ensuring that it happensconsistently is not easily achieved

Knowledge Translation

Getting the right informationto the right peoplein the right formatat the right time

with good impact

• Largest children’s rehabilitation hospital in Canada

• Vision: Create a world of possibility for kids with disability

• Teaching hospital fully affiliated with the University of Toronto

• Onsite Bloorview Research Institute

• Teaching and Learning Institute

Holland Bloorview Kids Rehabilitation Hospital

ShaunaKingsnorthEvidence toCare Lead

ChristineProvvidenzaKnowledgeTranslationSpecialist

JoannaWincentakKnowledge

Broker

AshleighTownley

KnowledgeBroker

The Evidence to Care Team

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Research in childhood disability

Considerations of usingresearch in healthcare

1950

Evidence-basedmedicine movement

1990

1975

Pediatric rehabilitationas an independent field

of study

Knowledge translationmodels gain recognition

2000

Our vision is to promote the best availableresearch evidence to inform care in

childhood disability.

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2. Merskey et al., 1979; 3. McCaffery et al.,1989; 4. IASP, 1986; 5. Merskey et al., 1994; 6. Dickinson et al., 2007

Select, tailor,implement

intervention

Assess barriersto knowledge

Use

Adaptknowledge tolocal context

Identify problem---------------

Identify, review,select knowledge

Sustainknowledge use

Evaluateoutcomes

Monitorknowledge use

www.hollandbloorview.ca/toolbox

Chronic Pain Toolbox for Children withDisabilities

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Review of Clinical Practice Guidelines

Clinical practice points =Disability lens

Systematic review=

Chronic paintools

Toolbox Implementation

• Implemented in 7 outpatient clinics at Holland Bloorview

Kids Rehabilitation Hospital

• Multi-component iKT strategy:

– Interactive consensus meetings to select tools

– Clinic flow pattern assessment

– Champions

– Education campaign

– Staff check-ins

– Documentation optimization

– Audit & feedback

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Pain champions

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Consensus activity

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Education campaign

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11. Provost et al., 2013

Huddles

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Documentation

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Audit & feedback

Impact

• 96% of children with pain had an assessment documented

• Clinicians think the Toolbox has led to some important changes:

– Assessing chronic pain more routinely and consistently

– Raised awareness of the need for explicit chronic painassessment

– More likely to use a validated pain assessment tool

– Talking about pain more directly, using more specific language

– More of a focus on pain interference/impact on daily activities

Knowledge push:

• Conferences• Webinars

• Twitter• Facebook

• Promotional materials

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AACPDM Transformative Practice Award

Dr. Chantel Barney Dr. Shauna Kingsnorth

Where are we?

Transformative Practice Award Parameters

• KT specific funding

• 15 month project

• $4000 USD

• In-kind time

• Tailoring of implementationstrategies to local context

• Barriers and facilitatorsassessment

• 2 onsite visits

Train-the-TrainerModel=

Contextual Factors – KT

Holland Bloorview

• KT Hub in existence for 3 years

– KT model & practices established

• 4 full-time KT experts

Gillette Children's

• Beginning of KT journey

– Exploring KT models & practices

• 1 part-time KT novice scientist

• Both sites:

• Senior managementsupport for KT

• Funding for KT roles

• Leads for pain project

• External funding key toproject progression

Contextual Factors – Pain Practice

Holland Bloorview

• Toolbox = demonstration projectwith Ministry of Health funding

• Protected time – 5 days per wk

Gillette Children's

• Toolbox = side of desk project

• Protected time – ½ day per wk

• Both sites:

• Academic and researchhospitals

• Pediatric focused

• Similar patient population

• Pain treated as the 5th vitalsign

Train-the-Trainer Model

• Relationship built on:

– Trust

– Transparency

• Core T-T-T activities:

– KT capacity building

– Openly shared all project documentsand templates

– Implementation strategy adaptation

– Evaluation and sustainability support

– Weekly coaching calls

– Comprehensive implementation plan

– Shared cloud storage service

– Decision/action log

– Face to face visits

• Enablers:

Processes

Accountability

Clear & frequentcommunication

Passionate people!

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GILLETTE CHILDREN’S SPECIALTY HEALTHCARELargest Rehabilitation Hospital in the upper mid-west, USA60 Inpatient beds4,000 patients with CP seen annually

GILLETTE CHILDREN’S SPECIALTY HEALTHCARELargest Rehabilitation Hospital in the upper mid-west, USA60 Inpatient beds4,000 patients with CP seen annually

KNOWLEDGE TRANSLATIONA GILLETTE PRIORITY

Looking todevelop a KTframework

Looking formodels of how

KT works

Clinical need forsystematic

assessment &documentationof chronic pain

KNOWLEDGE TRANSLATIONA GILLETTE PRIORITY

Gillette GOALS:• Improve chronic pain assessment for our patients

• Cultivate experience using the Knowledge-to-Action Cycle

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IMPLEMENTATION AT GILLETTE


intervention

Assess barriersto knowledge

Use

Adaptknowledge tolocal context

Identify problem---------------

Identify, review,select knowledge

Sustainknowledge use

Evaluateoutcomes

Monitorknowledge use

GETTING STARTEDADAPTING TO THE GILLETTE CONTEXT

Selectknowledge

Adapt tolocal context

Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

Knowledge toaction cycle

Selected clinics based on:

– CP population ITB pump maintenance clinics

– Risk for chronic pain Chronic pain clinics

– Feasibility Center for Gait & Motion Analysis

Provided baseline pain education to providers

– Clinical practice points provided in Toolbox

Created a process to store/audit in eDocs

PLANNING FOR SUCCESSIDENTIFYING BARRIERS AND FACILIATATORS

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use


Barriers

– Time constraints in clinic

– Maintaining clinic flow

– Outreach staff not on site for check-ins

– Learning curve/ time lag for making clinical decisionsbased on the data collected

– Interpretation of scores

Facilitators

PLANNING FOR SUCCESSIDENTIFYING BARRIERS AND FACILIATATORS

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use


Barriers

Facilitators

– Senior Leadership support for project

– Extreme willingness of providers

– Grant supported

– Audit process largely in place via eDocs

– Gait Lab had pre-clinic survey process in place

TOOL USAGECHOSEN TOOLS AT GILLETTE

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use


– Consensus building exercise to select tools to meetclinical needs

– Trial of chosen tools - Fall 2015

– Developed a new clinic process to integrate tools

– “Go live” with tools January 2016


Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use


Intrathecal Baclofen Pump Management Clinics• Paediatric Pain Profile

• PROMIS (child & parent report versions)

Chronic Pain Physician Specialists• Non-communicating Children’s Pain Checklist

• Pediatric Pain Questionnaire

• Paediatric Pain Profile

• Brief Pain Inventory

• Bath adolescent pain questionnaire(s)

• The Pain STAGES of change questionnaire – pain coping

Center for Gait and Motion Analysis• Child Self Efficacy Scale (CSES) – pain coping

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Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use


Intrathecal Baclofen Pump Management Clinics• Paediatric Pain Profile• PROMIS (child & parent report versions)• Brief Pain Inventory

Chronic Pain Physician Specialists• Non-communicating Children’s Pain Checklist• Pediatric Pain Questionnaire -> APPT• Paediatric Pain Profile• Brief Pain Inventory• Bath adolescent pain questionnaire(s)• The Pain STAGES of change questionnaire – pain coping

Center for Gait and Motion Analysis• Child Self Efficacy Scale (CSES) – pain coping

KEY STAKEHOLDERSIDENTIFIED AT GILLETTE

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use


– Providers Implementing the tools

– Nursing support staff

– Clinic Supervisors

– Clinic Directors

– Medical Director

– Health Information Services – audit process

– Research personnel – audit process

– Communications Team

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

Knowledge toaction cycleDATA

TOOL USAGE AT GILLETTE

– Monthly data pulls to assess uptake of the tools

– Graphic feedback to clinicians

– Support provided as needed

– Tools adjusted to meet clinical & feasibility needs

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use



0

10

20

30

40

50

60

70

80

90

100

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT

Pe

rce

nt

Imp

lem

en

tati

on

% Pediatric Patients with Chronic Pain Assessment Completed

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use



260

4218

66

91

64

BPI

NCCPC-R

PPQ

PROMIS

PPP

CSES

44%

12%

15%

16%

6%6%

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use



221

4218

66

91

64

Chronic Pain

Pain Coping

44%56%

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Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use



221

4218

66

91

64

221281

541 TOTAL ASSESSMENTS

800+ THOROUGH CHRONIC PAIN ASSESSMENTS COMPLETED

Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

Knowledge toaction cycleEVALUATION

What’s Next Survey

– Determine how the tools were working

Rapid Fire Interviews

– Assess clinical utility

– Identify areas of success

– Identify long term supports needed

– Sustainability ideas

EVALUATION

Time to useClinically

usefulI want to

keep usingBest fit

GMFCS levels

PPP (n=6)3-5 mins

Agree (4)Unsure (2)

Yes (6) IV-V

PROMIS (n=3)< 2 mins Agree (3)

Yes (1)Unsure (2)

child: I-IIIparent: III

NCCPC-R (1)6-10 mins Agree (1) Yes (1) IV-V

CSES (n=3)< 2 mins

Agree (2)Unsure (1)

Yes (2)Unsure (1)

I-IV

PPP (n=6)

PROMIS (n=3)

NCCPC-R (n=1)

CSES (n=3)

EVALUATION

What do you like? What don’t you like?

• Easy to administer• Comprehensive• Provides information on

comfort/spasticity even whenparents say pain is not an issue.

• Some behaviors measured are notspecific to pain

• Quick and easy to use• Provides more information• Less involved children can report

• Some items are not applicable• ‘when I had pain’ can be confusing

• The breadth and depth of thequestions for non-verbal children

• Nothing

• Simple and quick• Provides a dimension of pain coping

that we don’t otherwise collect

• Not always relevant• Psychometric properties unknown• No cut score

CSES (n=3)

NCCPC-R (n=1)

PROMIS (n=3)

PPP (n=6)

EVALUATIONHow is the information used in clinical practice?

• Characterizing pain, distress, and comfort• Used in relation to changing baclofen dose• Nice baseline for comparison over time/after intervention• Interventions can be made using this information

• Used in relation to changing baclofen dose• Compare scores over time• Gives us some information on function• It can expose the ways the child is impacted

• Gain better understanding of how the symptoms impact day-to-day life

• Score is provided in pain section of dictation• Information can prompt conversations about pain

CSES (n=3)

NCCPC-R (n=1)

PROMIS (n=3)

PPP (n=6)

EVALUATIONOverall, what do you think of the toolbox?

“It is far better than previous pain scales”

“I think it is helpful in clinic. I would like more direction on what to dowith high scores to properly address their pain, especially if they cannot

get a palliative care appointment right away.”

“This has been a great addition to our plan of care”

“It’s OK, but really hasn't changed my practice”

“It helps to make the assessment quick and easy and gives goodinformation”

“It is good to have tools for verbal & non verbal kids”

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Selectknowledge


Assessbarriers


Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use


SUSTAINABILITYAT GILLETTE

Planning informed by clinicians:

– Rapid fire interview & What’s next survey

– Workshop with visioning exercise

Gillette Toolbox Education Impact

Paediatric Pain Profile (non-verbal)Non-Communicating Children’s Pain Checklist (non-verbal)Brief Pain Inventory (all patients)Gillette-specific ‘Clinical Practice Points’

GILLETTE TOOLBOX

Internal newslettersRounding to relevant department meetingsBroad push by Clinical EducatorsCreation of staff training materialsChoosing additional target clinics

EDUCATIONAL CAMPAIGN

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Use clinical data for research purposes – Ethics approvedCollected chronic pain and patient factors from medical recordsDissemination of findings internally and externally

IMPACT

MOVING PAIN ASSESSMENT FORWARDA GILLETTE PRIORITY

NEXTAdditional clinics invited to participateInclude in electronic formatEducate and empower patients & families

Case Studies

“Mary” – ITB Dose Change“Casey” – Seating Evaluation

“Michael” – Surgery (pump & catheter revision)“Taylor” – ITB Dose Change

-the tools are quick and easy to use

-families like them!

-they can provide a concrete focus for clinical interventions

-the PPP collects data on distressing symptoms

CHOICE OF TOOL

Decision to add an Outcome Tool on a Dimension not Currently Assessing

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CHOICE OF TOOL

Potential to identify children who may be at risk for challengeswith pain management.

RESEARCH 2016

Data Completion Rate: 90% (427/473)

59%18%

12%

4%6%

1%

CP

Ortho

Neuro

Myelo

Genetic

Other

No Pain

Pain

37%52%

33%48% 46%

63%48%

67%52% 54%

CP (N=252) Ortho (N=77) Neuro (N=51) Myelo (N=19) Genetic (N=24)

PERCENTAGE OF PATIENTS WITH PAIN BY DIAGNOSIS

INCORPORATION INTO CLINICAL REPORT

Pain: Lydia complained of no pain or sensory issues during today's evaluation. Her mother reports that sheroutinely complains of pain in both feet with walking short or long distances, standing, stairs or uneven terrain,or at the beginning or end of the day. The Child Self-Efficacy Scale indicates that her mother is very unsure of herability to do things when she is in pain. Pediatric Outcome Data Collection Instrument pain score alsocorroborates some level of pain.

Child Self-Efficacy Scale - Parent (CSES-Parent): 307 = very sure able to do things when in pain21 = in the middle with regard to ability to do things when in pain35 = very unsure able to do things when in pain

NEXT STEPSGoal: Identify children who may be at risk for challenges with painmanagement.

Method: Follow a group of children through orthopaedic procedureand post-op gait analysis with pre-operative pain coping concerns.

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ResearchClinical Outcomes

Clinical Expertise

Patient Preferences& Values

KnowledgeTranslation

https://www.youtube.com/watch?v=CDbj7g4glJM

pain assessment without borders - aacpdm gillette priority looking to develop a kt framework looking...

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