EPEC - Pediatrics. Teaching Adult Professionals. Communication: Using Teaching (Interactive Lecture) as a Tool for Success

Transcription

1 Communication: Using Teaching (Interactive Lecture) as a Tool for Success Stefan J. Friedrichsdorf, MD, FAAP Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis/St. Paul, MN Associate Professor of Pediatrics, University of Minnesota Medical School Stefan.Friedrichsdorf@ChildrensMN.org Teaching Adult Professionals This graph, and similar pronouncements are fraudulent. people_remember.html National Training Center s pyramid graph of Average Learning Retention Rates EPEC - Pediatrics The Education in Palliative and End of Life Care: EPEC-Pediatrics Stefan J. Friedrichsdorf, Stacy Remke, Joshua Hauser, Joanne Wolfe Funded by the National Institute of Health / National Cancer Institute [1 R25 CA ] EPEC.Pediatrics@childrensMN.org

2 EPEC-Pediatric TEACHING! (1) Interactive Lecture! (2) Case Study! (3) Role Play TEACHING! (4) Skill Procedural Pain Management Redningskvinder Channel TV3 - (episode 7, Season 4.) 2014

3 Don't have enough staff for pediatric pain control...? Funny, how there is always enough staff to restrain a child. Pediatric Analgesia in 1985 Papoose Boards The grand and prevalent delusion... Knowledge Behavior

4 Life after Death by Powerpoint with Don McMillan Make lectures active Slides (for the visual learners) Cases (to show why its important) Videos (to change the pace and make it more relevant) Ask questions of the audience Rhetorical (no answers) A few comments Audience responses systems Ask them to discuss ( buzz groups ) Teaching Adult Professionals Needs Assessment Hook Attitude (Objective 1 on CME form!) Knowledge (Objective 2!) Skill (Objective 3!) Behavior (Change)

5 TEACHING o Needs Assessment: Flip chart o Trigger Video o Compelling data o Other ideas? o Recent case! (4) Skill TEACHING! (4) Knowledge! (3) Skill What are children most afraid of when coming to see a doctor? Friedrichsdorf S, Eull D, Weidner C: Children Are Actually Afraid of Needle Pokes. And their Parents, too. Journal of Duh! 2015:(1)1:1-518

6 Myths and Barriers to Prevent Needle Pain Case Scenario: Child undergoes routine needle procedures - you want to implement all the 4 non-negotiables (sitting upright, topical anesthesia, distraction & sucrose/breast-feeding for infants) What would be the most common concerns you might hear from your colleagues or parents arguing against using these modalities in this child?

7 TEACHING o Why would your colleagues (!) not do it...? o Group discussion, flip chart o Review counter arguments... o Other ideas?! (3) Skill TEACHING! (3) Skill Pain Assessment Big Hero 6 (2014)

8 What are we measuring...? (1) Nociceptive Pain: arises from the activation of peripheral nerve endings (nociceptors) that respond to noxious stimulation Somatic (for example, muscles, joints) Chronic somatic pain typically well localized & often results from degenerative processes (such as arthritis) Visceral (internal organs) (2) Neuropathic Pain: resulting from injury to, or dysfunction of, the somatosensory system. Central pain: caused by a lesion or disease of the central somatosensory nervous system (3) Psycho-social-spiritualemotional Pain / Total Pain (4) Chronic Pain Pain beyond expected time of healing 8-year old Nadia Pain Assessment Pediatric Pain - Status Quo Under treatment of pain in children Parents expect pain to be relieved Forgeron PA, Finley GA, Arnaout M. Pediatric pain prevalence and parents' attitudes at a cancer hospital in Jordan. J Pain Symptom Manage. 2006; 31(5): Priorities of parents of hospitalized children "Taking care of pain" rated as second highest priority (1st: getting right diagnosis) Ammentorp J, Mainz J, Sabroe S. Parents priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med 2005;159: Parents greatest distress: failing to protect their child from pain Tiedeman, M. (1997). Anxiety responses of parents during and after the hospitalisation of their 5 - to -11 year old children. Journal of Pediatric Nursing, 12(2), Melnyk BM. Intervention studies involving parents of hospitalized young children: an analysis of the past and future recommendations. J Pediatr Nurs Feb;15(1):4-13. Assumption: everything possible is done Anand s neonatal surgery studies

9 Pediatric Pain - Status Quo USA: adults receive more than two - three times as many analgesic doses as children (with identical diagnoses) (1) Eland JM, Anderson JE: The experience of pain in children. In: Jacox A (ed). Pain: a source book for nurses and other health care professionals. Boston: Little Brown & C0; 1977: (2) Beyer JE, DeGood DE, Ashley LC, Russell GA. Patterns of postoperative analgesic use with adults and children following cardiac surgery. Pain Sep;17(1): (3) Schechter NL, Allen DA, Hanson K. Status of pediatric pain control: a comparison of hospital analgesic usage in children and adults. Pediatrics Jan;77(1):11-5. The younger children are, the less likely they receive appropriate analgesia Broome ME, Richtsmeier A, Maikler V, Alexander M. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage May;11(5): ; Nikanne E, Kokki H, Tuovinen K. Postoperative pain after adenoidectomy in children. Br J Anaesth Jun;82(6): Compared to adults, pediatric patients receive fewer and/or incorrectly dosed analgesics in daily routine Ellis, J. A., O Connor, B. V., Cappelli, M., Goodman, J., Blouin, R., & Reid, C. W. (2002). Pain in hospitalized pediatric patients: How are we doing? Clinical Journal of Pain, 18, Inappropriate Analgesia: Why Bother...? Children with persistent pain suffer more physical symptoms in adult life, more anxiety and more depression 1946 Medical Research Council and 1958 National Child Development Study Inadequate analgesia for initial procedures in children diminishes effect of adequate analgesia in subsequent procedures Weisman SJ, Bernstein B, Schechter NL: Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med :147-9 Up to 25% of adults have fear of needles with most fears developing in childhood: avoidance of health care (including nonadherence with vaccination schedules Taddio A, Chambers CT, Halperin SA, et al. Inadequate pain management duringchildhood immunizations: the nerve of it. Clin Ther 2009;31(Suppl 2):S ) NICU: increased morbidity & mortality Anand KJ, Barton BA, McIntosh N, Lagercrantz H, Pelausa E, Young TE, et al. Analgesia and sedation in preterm neonates who require ventilatory support: results from the NOPAIN trial. Neonatal Outcome and Prolonged Analgesia in Neonates. Arch Pediatr Adolesc Med Apr;153(4):331-8 Trauma & post-traumatic stress disorder (PTSD) US soldiers after serious combat injury: Use of morphine during trauma care reduces risk of subsequent development of PTSD Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dougherty AL. Morphine use after combat injury in Iraq and post-traumatic stress disorder. The New England journal of medicine Jan 14;362(2): year-olds (n=24) with acute burns: Children receiving higher doses of morphine had greater reduction in PTSD symptoms over 6 months Saxe G, Stoddard F, Courtney D, Cunningham K, Chawla N, Sheridan R, et al. Relationship between acute morphine and the course of PTSD in children with burns. Journal of the American Academy of Child and Adolescent Psychiatry Aug;40(8): Children (n=48) with injury that led to hospital treatment: Morphine was associated with lower levels of PTSD at follow-up 6 months later Nixon RD, Nehmy TJ, Ellis AA, Ball SA, Menne A, McKinnon AC. Predictors of posttraumatic stress in children following injury: The influence ofappraisals, heart rate, and morphine use. Behaviour research and therapy Aug;48(8) to 48-month-old (n=70) children with acute burns admitted to major pediatric burn center: Management of pain with higher doses of morphine associated with decreasing number of symptoms of PTSD in months after major trauma. Stoddard FJ, Jr., Sorrentino EA, Ceranoglu TA, Saxe G, Murphy JM, Drake JE, et al. Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms in one- to four-year-olds with burns. J Burn Care Res Sep-Oct;30(5):

10 Pain in the Neonate: Why bother? Neonates at 33 weeks gestational age admitted to NICU experienced average of 10 painful procedures / day; 79 % were performed without any type of analgesia. Carbajal, R., Rousset, A., Danan, C., Coquery, S., Nolent, P., Ducrocq, S., et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. The Journal of the American Medical Association 2008, 157, Poorly managed pain has serious short- and long term consequences: Each painful event causes immediate physiological and behavioral instability Holsti L, Grunau RE, Oberlander TF, Whitfield MF. Specific Newborn Individualized Developmental Care and Assessment Program movements are associated with acute pain in preterm infants in the neonatal intensive care unit. Pediatrics Jul;114(1): Significant relationship between physiological markers of neonatal pain and oxidative stress Slater L, Asmerom Y, Boskovic DS, Bahjri K, Plank MS, Angeles KR, et al. Procedural pain and oxidative stress in premature neonates. The journal of pain 2012 Jun; 13(6): Repetitive procedural pain in preterm infants is associated with reduced early body growth and head circumference, after accounting for multiple medical confounders Vinall, J., S. P. Miller, et al. (2012). "Neonatal pain in relation to postnatal growth in infants born very preterm." Pain 153(7): Procedural pain: A Call for Action Pain ratings at 4-6 months routine vaccination higher for circumcised versus uncircumcised boys Taddio A (1994) Lancet, 344:291-2 Preterm infants: Poorer cognition and motor function associated with higher number of skin-breaking procedures Grunau RE, Whitfield MF, Petrie-Thomas J, Synnes AR, Cepeda IL, Keidar A, et al. Neonatal pain, parenting stress and interaction, in relation to cognitive and motor development at 8 and 18 months in preterm infants. Pain May;143(1-2): Memory of previous painful experience has great influence on pain experience during subsequent procedures Versloot J, Veerkamp JSJ, Hoogstraten J: Children s self-reported pain at the dentist. Pain : TEACHING o Slides - add photos? o Build slide by bulletpoints o Videos (copyright!) o Your own case video o Humor... o Clear outline o Other ideas?! (4) Skill

11 TEACHING! (4) Skill Teaching Pediatric Pain Medicine & Research in your institution Please think about your next important presentation - what are you going to do to change the behavior of the audience? Please discuss in small group on table Share your top 1-2 items on flip chart, please TEACHING! (4) Skill o o o Case example Small / large group work Other ideas?

12 TEACHING! (4) Skill Teaching skills Know your material Prepare room and test AV equipment Be prepared to answer questions Use humor appropriately Be prepared for challenging participants Do NOT read to the audience Rehearse, rehearse, rehearse Bad Presenter Bingo Uses laser on every slide Skips through 2nd half of slides In the interest of time Faces screen or laptop, not you Doesn t know how to operate the klicker to advance slides Cannot start the first slide Does no leave time for questions Too many bullet points Using standard Font & Color schemes on PowerPoint slides Has no summary slide Font smaller than 20 points Too far away from microphone Uses table copied from article Too many words on one slide JOKER Has too many slides JOKER Apologizes for presentation Runs over assigned time Confusing chart or graphic (double if shading & 3-D effect) Objectives start with Review or Discuss Reads slides to you Handout not correlating with slides at all I know this is a little busy Runs over assigned time Stays glued behind the podium

13 Teaching: Overall Message How information is taught is important to retention and implementation Learn how to teach: EPEC-Pediatrics & Professional Development Workshop (PDW) Do you remember Marius...? How about a Plan B? LET Anesthesia Sitting upright Distraction Topical Anesthesia Sucrose (0-12 months) 3mL LET-gel: Lidocaine 4%- Epinephrine 0.18% -Tetracaine 0.5% Singer AJ, Stark MJ. Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: a randomized doubleblind trial. Acad Emerg Med Jul;7(7):751-6.

14 Further Training: 9th Annual Pediatric Pain Master Class Minneapolis, MN June 11-17, 2016 Education in Palliative & End-of-life Care [EPEC]: Become an EPEC-Pediatrics Trainer Chicago, IL March 12-13, 2016 (Professional Development Workshop March 9, 2016) Stefan J. Friedrichsdorf, MD, FAAP Associate Professor of Pediatrics, University of Minnesota Medical School Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Children's Hospitals and Clinics of Minnesota 2525 Chicago Ave S Minneapolis, MN USA phone fax stefan.friedrichsdorf@childrensmn.org Blog: