TABLE 1.
Studies of the effect of standardized pain assessment tools on pediatric patient or process outcomes
| Author (reference), country | Setting, sample | Design | Interventions* | Patient or process outcomes | Methodological issues |
|---|---|---|---|---|---|
| Boughton et al (18), USA | Single pediatric ward, general hospital
Convenience sample, postoperative (n=50 pre, n=36 post) Age: 5 to 17 years |
Pre/post comparison (clinical audit)
Pre sample obtained by retrospective chart review (interval unspecified) |
T: WBFPS | Patient: No difference in analgesic efficacy, use of other pain control methods; no difference in progress of ambulation or length of stay
Process: No difference in amount of analgesia received |
Not reported: Amount of teaching provided, uptake, inter-rater reliability, where assessment was documented or if treatment protocols were used |
| Buchanan et al (19), Saudi Arabia | 2 pediatric wards, general hospital
Convenience sample, high risk for pain (n=40 pre, n=40 post-1; n=40 post-2) Age: 0 to 14 years |
Pre/post comparison (clinical audit)
3 times over 8 months |
E: CQI
T: PPAT D: Pain assessment and treatment chart G: Pain management guideline |
Process: No difference in use of nonpharmacological interventions or in amount of analgesia received (continued 90% analgesia treatment); increased assessment, re-evaluation and documentation to near 100% at 3 months; some aspects decreased to approximately 70% at 6 months; some differences based on patient age, sex | Not reported: Amount of teaching provided, uptake, inter-rater reliability |
| Ellis et al (20), Canada | 5 pediatric wards, general hospital
Convenience sample (n=75 pre, n=44 post-1, n=50 post-2) Age: Unspecified |
Pre/post comparison (clinical audit)
3 times (interval unspecified) |
E: Inservice and coaching
T: Pain assessment scales (not specified) D: New documentation G: Standard care plan for pain management |
Patient: Decreased % of patients with pain ≥5/10 (12%)
Process: Use of pain scales increased at post-1, decreased at post-2; narrative description of pain increased at post-1 and post-2 |
Some description of education methods and duration
Not reported: Uptake or inter-rater reliability; random selection of 10% of all available records (post-1), patients likely to have pain (post-2) |
| Falanga et al (21), Canada | Single pediatric ward, general hospital
Convenience sample (pre), all eligible (post), trauma, surgery, painful medical conditions (n=56 pre, n=56 post) Age: 5 to 17 years |
Pre/post comparison (1 year after pre) | E: Inservice
T: Colour/word graphic scale, VAS Pain treatment algorithm |
Patient: Pain intensity decreased post from 1.5 to 2.1 points; no difference in side effects
Process: Nonopioid and combined analgesia use increased |
Not reported: Amount of teaching provided, uptake, inter-rater reliability |
| Franck et al (15), UK | All wards, children’s hospital
Randomized, postoperative sample (n=49 control; n=37 intervention) Age: 6 to 12 years |
RCT | T: WBFPS child temporary tattoo versus nurse-held paper version | Patient: Child/parent satisfaction increased in intervention group
Process: No difference in pain assessment documentation or analgesia given |
Confounded by strong effect of pain service and/or PCA on amount of documentation and treatment; underpowered |
| Furdon et al (22), USA | NICU, children’s hospital
All ventilated neonates after abdominal surgery (n=14 pre, n=15 post) |
Pre/post comparison (clinical audit)
Samples obtained by retrospective chart review (1 year before and 1 year after 2-year intervention) |
E: CQI
T: NIPS G: Standard care plan for pain management |
Patient: Decreased side effects, length of intubation (by 33%), length of stay (by 20%); return to preoperative weight sooner
Process: Increased documentation of assessment/reassessment and effectiveness; increased patients receiving analgesia and continuous infusion; decreased use of bolus morphine and overall consumption |
Not reported: Amount of teaching provided, uptake, inter-rater reliability
No statistical analysis of findings |
| Hamers et al (23), The Netherlands | Single pediatric ward, general hospital
Randomized, postoperative sample tonsillectomy ± adenoidectomy (n=42 control, n=41 intervention) Age: 3 to 6 years and 7 to 12 years |
Pre/post (nested within RCT) | T: Various
G: RCT of acetaminophen ± fentanyl or placebo |
Patient: No differences in pain scores, ability to drink or sleep up to 3 h after surgery | Standardized pain assessment tools introduced to both groups midway in the trial; may have been underpowered |
| Johnston et al (16), Canada | Multiple (unspecified) pediatric wards, 6 hospitals (3 children’s hospitals)
Hospitals randomized, patient chart sampling unspecified (n=464, 306 [985 charts] pre, 158 [617 charts] post) Age: Unspecified |
Cluster RCT
Pre/post comparison Prospective review of patient charts 2 weeks pre and (interval unspecified) post |
E: 1-to-1 coaching using think aloud process
T: Encouraged to use standardized pain assessment tools (various) G: Encouraged to implement evidence-based pain management and guidelines (some sites only) |
Process: Increased documentation of pain assessment (10% to 40%) and nonpharmacological treatments (11%) for intervention hospitals but not control sites; no difference in amount of analgesia at intervention sites; decrease in analgesia at control sites | Not reported: Details of type and amount of coaching received per nurse
Difficulties in recruitment and retention in the study Large variability across sites not accounted for in analysis and may confound findings |
| Jordan-Marsh et al (26), USA | Multiple (unspecified) pediatric wards, general hospital
Random selection of 10% of patient charts (unspecified) at each time point Age: Unspecified |
Pre/post (serial) comparisons during and after 2-phase, 3-year intervention | E: CQI
T: Poker Chip Tool G: Clinical practice guideline; pain management rounds |
Process: Increased documentation of assessment (30%) and effectiveness (9%); increased amount of analgesia (87%) and change in types of drugs given | Not reported: Amount of teaching provided, uptake, inter-rater reliability
Insufficient details about samples at all measurement points |
| Joyce et al (25), USA | Single surgical ward, children’s hospital
Prospective review of all patient charts for 48 h, all children admitted at each time point (n=20 pre, n=22 post) Age: 3 to 6 years |
Pre/post comparisons (6 weeks after intervention) | T: Various
D: Pain assessment and management flowsheet |
Patient: No difference in parent satisfaction
Process: Decreased pain assessment or management documentation; no difference in documentation of analgesia; increased documentation of nonpharmacological intervention |
Not reported: How intervention was implemented
High levels of parent satisfaction before intervention |
| Oakes et al (27), USA | Entire children’s cancer hospital
All patient charts for 87 24 h periods (n=2478) Age: Newborn to young adult |
Pre/post comparisons (quarterly over 6 years) | E: Coaching, CQI
T: Pain assessment scales (NRS, WBFPS, FLACC) D: New documentation G: Pain management protocol |
Patient: Decreased number of patients with pain scores ≥5 (9%)
Process: Increased documentation of assessment (13%) |
Not reported: Amount of teaching provided, uptake, inter-rater reliability
No statistical analysis of findings |
| Stevens (14), Canada | 1 pediatric ward, general hospital
Random sample, postoperative patients (n=20 intervention, n=23 control) Age: 1.5 to 12 years |
RCT | T: VAS, CHEOPS
D: Pain assessment and management flowsheet |
Patient: Decreased mean pain scores by 2.6 points
Process: Increased pain assessment in intervention group (every 4 h versus every 6 h); increased ratings by parents and children in intervention group; increased analgesia administration (25%) in intervention group; no difference in length of stay |
Not reported: Amount of teaching provided, uptake, inter-rater reliability |
| Treadwell et al (24), USA | Hematology/oncology ward, children’s hospital
Random sample (n=36 pre, n=49 post) Age: 0 to 18 years |
Pre/post comparison (1-year interval) | E: CQI
T: CHEOPS, WBFPS, VAS G: Pain assessment protocol |
Patient: Increased patient satisfaction with pain tools; no difference in pain or mood ratings or effectiveness of analgesia
Process: Increased documentation of assessments; use of nondrug interventions and speed of staff response to complaints of pain |
Not reported: Amount of teaching provided, uptake, inter-rater reliability |
| Vihunen and Sihvonen (17), Finland | 2 pediatric wards, general hospital
Sampling unspecified, postoperative tonsillectomy (n=80 pre, n=80 post, 40 each ward) Age: 3 to 8 years |
RCT: Ward randomized | T: WBFPS | Patient: Decreased pain on intervention ward (P<0.05); increased parent satisfaction differences in pain | Methods of implementation not detailed in English abstract; management not controlled between 2 wards |
*
E Education; D New pain documentation system; G Pain treatment guideline; T New assessment tool. CHEOPS Children’s Hospital of Eastern Ontario Pain Scale; CQI Continuous quality improvement; FLACC Faces, Legs, Activity, Cry, Consolability scale; NICU Neonatal intensive care unit; NIPS Neonate and Infant Pain Score; NRS Numeric rating scale; PCA Patient-controlled analgesia; Post Postintervention; PPAT Pediatric Pain Assessment Tool; Pre Preintervention; RCT Randomized controlled trial; VAS Visual analogue scale; WBFPS Wong-Baker FACES Pain Scale