Stony Brook Children's Hospital follows pain management protocols to treat pain in pediatric patients

Sep 30 2015

Stony Brook Children's Hospital clinicians follow pain management protocols to proactively, preemptively, and consistently treat pain in each and every pediatric patient. Known as the Ouchless Approach to Pediatric Medicine, Margaret McGovern, MD, PhD, Physician-in-Chief, describes it as the cornerstone of treatment for pediatric patients at Stony Brook Children's. Designed to specifically address acute pain, the approach acknowledges that many children arrive in pediatric emergency departments in different levels of pain, following an injury or because of an illness, etc. And clinicians often have to give injections, reset broken bones, and do other procedures may result in pain or discomfort in patients.

Acute Pain Management is Well-Understood, Supported by National Medical Organizations and Medical Literature

Unlike some conditions, medical literature has a lot of information about acute pain. And research has demonstrated the safety and efficacy of acute pain management, as well as the long-term risks of under-treating or not treating acute pain. Studies have found that newborns exposed to pain without anesthesia show exaggerated responses to painful stimuli later in life.

The Ouchless Approach protocols at Stony Brook Children's aim to reduce gaps between knowledge and what is done to treat acute pain. The protocols involve the use of evidence-based treatment methods, and are recommended by both the American Academy of Pediatrics and the Institute of Medicine.

Ouchless Approach involves Teaching Clinicians-in-Training to Address Acute Pain

As an academic teaching hospital, medical students and residents at Stony Brook Children's are trained to take a few moments to think about how to manage pain before a procedure. "It doesn't take much time and few situations require immediate action before pain medication can be given," says Sergey Kunkov, MD, MS, MBA Director of the Pediatric Emergency Department. "Even if a procedure is expected to last just a few seconds, something could happen and the procedure could last longer than anticipated, or it could be remembered by a patient as some of the worst few seconds of their life. Simple, effective treatments are readily available to mitigate pain, so even minimal pain during a procedure is just not necessary."

Dr. Kunkov explains further, "We teach our clinicians to ask the right questions and to look for non-verbal clues. A child who is in pain may say 'no' if asked whether they want pain medication, because they anticipate a 'scary' needle or a 'yucky' medicine. Instead, at Stony Brook Children's we teach our doctors and nurses to ask a child whether they're in pain and how much. Clinicians need to recognize an ashen expression and other visual signs of pain — this is very important if a child is unable or unwilling to speak."

Through the above-described education, clinicians are taught to set aside common misconceptions about pain management: that it takes too long, is inconvenient, too expensive, and unnecessary for a short or minimally painful procedures.

Ouchless Medicine in Practice — Combines Therapeutic Options and Distraction Techniques

The Ouchless Approach at Stony Brook Children's starts in the pediatric emergency department's triage unit. "If a child is expected to need an IV, a triage nurse will apply a numbing cream where the IV is likely to be placed. If a child comes in with an obvious injury, such as a broken leg, pain medicine, such as short-acting analgesic intranasal spray, or calming medication for anxiety, is given in triage," says Dr. Kunkov.

Clinicians follow the same basic safety principles used before any medication is given — first asking about known allergies, and any medications the child is current taking. "It takes less than a minute to assess risks of pain management; and most patients are unlikely to be allergic to pain medications, or to have a contraindication," says Dr. Kunkov.

The Stony Brook Children's team of Child Life Specialists — full-time staff trained to make children's experiences more comfortable and less stressful — are another vital component of the Ouchless Approach. Child Life team members work to engage and distract pediatric patients, which in turn reduces their parents' anxiety, which is very important since children often mimic or react strongly to feelings displayed by their parents.

"Therapeutic interventions are just part of our Ouchless program," says Dr. Kunkov. "To this day, I don't know what works better, pain medication or good distraction. I think it's often equal, and combined even better. Once a child's mind is off the treatment, a procedure or treatment often proceeds much more smoothly than it may have otherwise."

The Child Life team also teaches clinicians how to use simple distraction techniques to ease a child's or a parent's anxiety. Distractions range from simple things, such as video games on iPads, to starting an exam by talking to the child's doll, looking for doll's boo-boo, giving it 'treatment', etc.

"I've learned a lot from our Child Life team, particularly how to phrase something so it's less scary to a child. For example, instead of talking about stitches, to instead say that we have 'new super cool shoelaces for your cut - but we only have black or blue, which do you choose?'" says Dr. Kunkov

Using New Tools as Part of the Ouchless Approach

Since finding a suitable vein can be sometimes be a challenge on patients, and no one enjoys repeated needle sticks, Stony Brook Children's clinicians have recently begun using a vein illumination device, known as AccuVein, to help them visualize a vein. Benefits of the device include improved vascular access, improved patient satisfaction and comfort, and lower costs in both labor and supplies.

The technology is recommended by the Infusion Nurses Society. Several devices were recently purchased for Stony Brook Children's by the Stony Brook Medicine Auxiliary.

Halo Effect of the Ouchless Approach

"While other institutions have child life specialists on staff or do some things to make children more comfortable during treatments, Stony Brook Children's has one of the most comprehensive programs nationwide," says Dr. McGovern. "As a result of patient and clinician satisfaction with the program, we have extended the Ouchless Approach into nearly all areas of Stony Brook Children's patient care."

Parents of hematology/oncology patients are routinely given prescriptions for numbing cream, which they can apply to their children's arms before bring them to appointments, where they often require blood draws or other potentially uncomfortable procedures.

Endoscopy technicians now routinely apply numbing cream before inserting an IV. And Dr. Kunkov and his team are currently training local EMS in using acute pain management protocols during patient transports.

Additionally, several vein illumination devices are now being used in our adult emergency department and in Radiology.

Acute Pain Management Urged for Pediatric Patient Care Settings

"Every hospital and community practice should have a protocol for how to deal with pediatric pain. This can involve simple things — e.g., rapid assessment and treatment of kids with broken limbs or obvious injuries. Acute pain management protocols shouldn't necessitate special knowledge of pediatric sedation," says Dr. Kunkov.

If a hospital or clinician doesn't raise the subject of acute pain management, Dr. Kunkov encourages parents to ask about it. "I've brought my own child to the Stony Brook Children's pediatric emergency department, and being able to to experience our Ouchless Approach as a parent made its benefits even clearer to me than they were before."

Source: Stony Brook Children's Hospital