8/15/2017. Getting the right information to the right people in the right format at the right time with good impact

Transcription

1 Objectives Learn about the: Pain ment Without Borders: Keeping chronic pain assessment at the forefront of care for children with cerebral palsy Ashleigh Townley, Chantel Barney, Jean Stout, Jean Stansbury September 16, 2017 Chronic Pain ment 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 an expectation of all health care professionals in leading academic health sciences centres around the world; however ensuring that it happens consistently is not easily achieved Knowledge Translation Getting the right information to the right people in the right format at the right time with good impact Holland Bloorview Kids Rehabilitation Hospital The Evidence to Care Team 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 Shauna Kingsnorth Evidence to Care Lead Christine Provvidenza Knowledge Translation Specialist Joanna Wincentak Knowledge Broker Ashleigh Townley Knowledge Broker 1

2 Research in childhood disability Considerations of using research in healthcare Evidence-based medicine movement Our vision is to promote the best available research evidence to inform care in childhood disability Pediatric rehabilitation as an independent field of study 2000 Knowledge translation models gain recognition intervention to Use Adapt to Identify problem Identify, review, select 2. Merskey et al., 1979;3. McCaffery et al.,1989;4.iasp, 1986;5. Merskey et al.,1994;6. Dickinson et al.,2007 Photo by Hammonton Photography - Creative Commons Attribution-NonCommercial License Chronic Pain Toolbox for Children with Disabilities 2

3 Review of Clinical Practice Guidelines Clinical practice points = Disability lens Toolbox Implementation Implemented in 7 outpatient clinics at Holland Bloorview Kids Rehabilitation Hospital Systematic review = Chronic pain tools Multi-component ikt strategy: Interactive consensus meetings to select tools Clinic flow pattern assessment Champions Education campaign Staff check-ins Documentation optimization Audit & feedback Pain champions Consensus activity Photo by Hamed Saber - Creative Commons Attribution License Photo by zeevveez - Creative Commons Attribution License 3

4 Education campaign Huddles 11. Provost et al., 2013 Photo by Mark Brannan - Creative Commons Attribution-NonCommercial-ShareAlike License Photo by joncandy - Creative Commons Attribution-ShareAlike License Documentation Audit & feedback Photo by skoeber - Creative Commons Attribution-NonCommercial-ShareAlike License Photo by highersights - Creative Commons Attribution-NonCommercial-ShareAlike License Impact 96% of children with pain had an assessment documented Clinicians think the Toolbox has led to some important changes: ing chronic pain more routinely and consistently Raised awareness of the need for explicit chronic pain assessment More likely to 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 4

5 AACPDM Transformative Practice Award Where are we? Dr. Chantel Barney Dr. Shauna Kingsnorth Transformative Practice Award Parameters Contextual Factors KT KT specific funding 15 month project $4000 USD In-kind time Tailoring of ation strategies to = Train-the-Trainer Model Both sites: Senior management support for KT Funding for KT roles Holland Bloorview KT Hub in existence for 3 years Leads for pain project External funding key to project progression Gillette Children's Beginning of KT journey Barriers and facilitators assessment 2 onsite visits KT model & practices established 4 full-time KT experts Exploring KT models & practices 1 part-time KT novice scientist Contextual Factors Pain Practice Train-the-Trainer Model Both sites: Academic and research hospitals Pediatric focd Holland Bloorview Toolbox = demonstration project with Ministry of Health funding Protected time 5 days per wk Similar patient population Pain treated as the 5 th vital sign Gillette Children's Toolbox = side of desk project Protected time ½ day per wk Relationship built on: Trust Transparency Enablers: Processes Accountability Clear & frequent communication Passionate people! Core T-T-T activities: KT capacity building Openly shared all project documents and templates Implementation strategy adaptation Evaluation and sustainability support Weekly coaching calls Comprehensive ation plan Shared cloud storage service Decision/action log Face to face visits 5

6 GILLETTE CHILDREN S SPECIALTY HEALTHCARE Largest RehabilitationHospitalin the upper mid-west, USA 60 Inpatient beds 4,000 patientswith CP seen annually KNOWLEDGE TRANSLATION A GILLETTE PRIORITY KNOWLEDGE TRANSLATION A GILLETTE PRIORITY Looking to develop a KT framework Looking for models of how KT works Clinical need for systematic assessment & documentation of chronic pain Gillette GOALS: Improve chronic pain assessment for our patients Cultivate experience using the Knowledge-to-Action Cycle 6

7 IMPLEMENTATION AT GILLETTE intervention to Use Adapt to Identify problem Identify, review, select GETTING STARTED ADAPTING TO THE GILLETTE CONTEXT ed 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 SUCCESS IDENTIFYING BARRIERS AND FACILIATATORS Barriers Time constraints in clinic Maintaining clinic flow Outreach staff not on site for check-ins Learning curve/ time lag for making clinical decisions based on the data collected Interpretation of scores Facilitators PLANNING FOR SUCCESS IDENTIFYING BARRIERS AND FACILIATATORS 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 USAGE CHOSEN TOOLS AT GILLETTE Consensus building exercise to select tools to meet clinical needs Trial of chosen tools - Fall 2015 Developed a new clinic process to integrate tools Go live with tools January 2016 TOOL USAGE CHOSEN TOOLS AT GILLETTE 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 7

8 TOOL USAGE CHOSEN TOOLS AT GILLETTE KEY STAKEHOLDERS IDENTIFIED AT GILLETTE 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 Providers Implementing the tools Nursing support staff Clinic Supervisors Clinic Directors Medical Director Health Information Services audit process Research personnel audit process Communications Team DATA 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 DATA TOOL USAGE AT GILLETTE Percent Implementation % Pediatric Patients with Chronic Pain ment Completed JAN FEB MAR APR MAY JUN JUL AUG SEP OCT DATA TOOL USAGE AT GILLETTE DATA TOOL USAGE AT GILLETTE 44% 260 6% 42 6% % 15% 91 12% 64 BPI NCCPC-R PPQ PROMIS PPP CSES 44% % Chronic Pain Pain Coping 8

9 DATA 800+ THOROUGH CHRONIC PAIN ASSESSMENTS COMPLETED TOOL USAGE AT GILLETTE 541 TOTAL ASSESSMENTS EVALUATION What s Next Survey Determine how the tools were working Rapid Fire Interviews clinical utility Identify areas of success Identify long term supports needed ability ideas EVALUATION PPP (n=6) PPP (n=6) PROMIS (n=3) PROMIS (n=3) NCCPC-R (1) NCCPC-R (n=1) CSES (n=3) CSES (n=3) Time to 3-5 mins Clinically ful Agree (4) Unsure (2) < 2 mins Agree (3) I want to keep using Yes (6) Yes (1) Unsure (2) Best fit GMFCS levels IV-V child: I-III parent: III 6-10 mins Agree (1) Yes (1) IV-V < 2 mins Agree (2) Unsure (1) Yes (2) Unsure (1) I-IV EVALUATION PPP (n=6) PROMIS (n=3) NCCPC-R (n=1) CSES (n=3) What do you like? Easy to administer Comprehensive Provides information on comfort/spasticity even when parentssay pain is not an issue. Quick and easy to Provides more information Less involved children can report The breadth and depth of the questions for non-verbal children Simple and quick Provides a dimension of pain coping that we don t otherwise collect What don t you like? Some behaviors measured are not specific to pain Some items are not applicable when I had pain can be confusing Nothing Not always relevant Psychometric properties unknown No cut score EVALUATION PPP (n=6) PROMIS (n=3) How is the information d 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 EVALUATION Overall, 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 do with 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 NCCPC-R (n=1) CSES (n=3) Gain better understanding of how the symptoms impact dayto-day life Score is provided in pain section of dictation Information can prompt conversations about pain It s OK, but really hasn't changed my practice It helps to make the assessment quick and easy and gives good information It is good to have tools for verbal & non verbal kids 9

10 SUSTAINABILITY AT GILLETTE Planning informed by clinicians: Rapid fire interview & What s next survey Workshop with visioning exercise Gillette Toolbox Education Impact GILLETTE TOOLBOX EDUCATIONAL CAMPAIGN Paediatric Pain Profile (non-verbal) Non-Communicating Children s Pain Checklist (non-verbal) Brief Pain Inventory (all patients) Gillette-specific Clinical Practice Points Internal newsletters Rounding to relevant department meetings Broad push by Clinical Educators Creation of staff training materials Choosing additional target clinics 10

11 MOVING PAIN ASSESSMENT FORWARD A GILLETTE PRIORITY IMPACT Use clinical data for research purposes Ethics approved Collected chronic pain and patient factors from medical records Dissemination of findings internally and externally Additional clinics invited to participate Include in electronic format Educate and empower patients & families NEXT 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 -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 ing 11

12 CHOICE OF TOOL Potential to identify children who may be at risk for challenges with pain management. RESEARCH 2016 Data Completion Rate: 90% (427/473) PERCENTAGE OF PATIENTS WITH PAIN BY DIAGNOSIS 1% 12% 4% 6% CP Ortho Neuro 63% 48% 67% 52% 54% No Pain Pain 18% 59% Myelo Genetic Other 37% 52% 33% 48% 46% CP (N=252) Ortho (N=77) Neuro (N=51) Myelo (N=19) Genetic (N=24) INCORPORATION INTO CLINICAL REPORT NEXT STEPS Goal: Identify children who may be at risk for challenges with pain management. Pain: Lydia complained of no pain or sensory issues during today's evaluation. Her mother reports that she routinely 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 her ability to do things when she is in pain. Pediatric Outcome Data Collection Instrument pain score also corroborates some level of pain. Child Self-Efficacy Scale - Parent (CSES-Parent): 30 7 = very sure able to do things when in pain 21 = in the middle with regard to ability to do things when in pain 35 = very unsure able to do things when in pain Method: Follow a group of children through orthopaedic procedure and post-op gait analysis with pre-operative pain coping concerns. 12

13 Clinical Outcomes Research Patient Preferences & Values Knowledge Translation Clinical Expertise 13