The social ecology of changing pain management: do I have to cry?

Abstract

Objective: To improve acute pain management for children with systematic assessment and appropriate analgesia. Design: An action research design was used; pre-post data were collected during a four-phase intervention. The intervention was a social ecological approach to changing pain assessment and prescription practices. Setting: A university-affiliated public hospital in the greater Los Angeles area. Participants: An interdisciplinary team of clinicians and hospital administrators were engaged in implementing new pain management procedures for children with postoperative and procedural pain. Interventions: We implemented the Poker Chip Tool as a standard pain assessment tool, changed policy to make morphine drug of choice for acute postoperative pain, provided extensive educational activities, and conducted weekly rounds with anesthesiologist/intensivist, nurses, pharmacist, and child life specialist. Role modeling by leaders was used to build skill in interdisciplinary collaboration for staff. We promoted the initiative as an activity of the medical center strategic plan. Efforts were linked to national shifts in pain management through guideline review and use of a visiting expert. Outcome measures: Charts were audited for assessment of pain intensity. Doses dispensed by pharmacy were used as a proxy measure of analgesia administered to children to establish change in pattern of analgesic use. Results: In Phase I: 54% of charts audited had documentation of pain intensity. This rate climbed to Phase II, 93% of the audited charts at full implementation and stabilized at 84% at the project conclusion. Record of doses of analgesia dispensed demonstrated a shift from reliance on meperidine to morphine and acetaminophen with codeine. The relative rates demonstrated a 100% increase in acetaminophen with codeine distributed from the beginning of the study to full implementation of the project (χ 2 = 9.01, df = 1, p < 0.002). The relative rate for meperidine demonstrated a 250% decrease (χ 2 = 12.26, df = 1, p < 0.0004), and the relative rate for morphine exhibited a 455% increase (χ 2 = 209.20, df = 1, p < 0.0001). By the final phase (IV: Evaluation), meperidine was only 1% of the analgesia dispensed. Morphine doses that were initially 35% climbed to 62% at the close of the study. Acetaminophen with codeine shifted correspondingly from 24% to 36%. Anecdotal reports suggested that skills in assessment and building collaboration generalized to other patient care situations. Conclusions: Using a social ecology approach that focused simultaneously on the environment (ward, medical center, and national scene) and relationships among the clinical team improved pain management practices. These changes took place over 2 years and were sustained 2 years after the intense intervention.