title: Pain in hospitalized children: Effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes.
abstract: Hospitalized children frequently receive inadequate pain assessment and management despite substantial evidence to support effective pediatric pain practices. The objective of this study was to determine the effect of a multidimensional knowledge translation intervention, Evidence-based Practice for Improving Quality (EPIQ), on procedural pain practices and clinical outcomes for children hospitalized in medical, surgical and critical care units. A prospective cohort study compared 16 interventions using EPIQ and 16 standard care (SC) units in 8 Canadian pediatric hospitals. Chart reviews at baseline (time 1) and intervention completion (time 2) determined the nature and frequency of painful procedures and of pain assessment and pain management practices. Trained pain experts evaluated pain intensity 6 months post-intervention (time 3) during routine, scheduled painful procedures. Generalized estimating equation models compared changes in outcomes between EPIQ and SC units over time. EPIQ units used significantly more validated pain assessment tools (P<0.001) and had a greater proportion of patients who received analgesics (P=0.03) and physical pain management strategies (P=0.02). Mean pain intensity scores were significantly lower in the EPIQ group (P=0.03). Comparisons of moderate (4-6/10) and severe (7-10/10) pain, controlling for child and unit level factors, indicated that the odds of having severe pain were 51% less for children in the EPIQ group (adjusted OR: 0.49, 95% CI: 0.26-0.83; P=0.009). EPIQ was effective in improving practice and clinical outcomes for hospitalized children. Additional exploration of the influence of contextual factors on research use in hospital settings is required to explain the variability in pain processes and clinical outcomes.
authors.affiliation: The Hospital for Sick Children, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Bonnie J
authors.initials: BJ
authors.lastname: Stevens
authors.forename: Janet
authors.initials: J
authors.lastname: Yamada
authors.forename: Carole A
authors.initials: CA
authors.lastname: Estabrooks
authors.forename: Jennifer
authors.initials: J
authors.lastname: Stinson
authors.forename: Fiona
authors.initials: F
authors.lastname: Campbell
authors.forename: Shannon D
authors.initials: SD
authors.lastname: Scott
authors.forename: Greta
authors.initials: G
authors.lastname: Cummings
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002170:Canada; D002648:Child; D002673:Child, Hospitalized; D002675:Child, Preschool; D015331:Cohort Studies; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008297:Male; D010146:Pain / Q000175:diagnosis* / Q000453:epidemiology; D059408:Pain Management; D010147:Pain Measurement; D018401:Sample Size; D013997:Time Factors; D057170:Translational Research, Biomedical
keywords: Intervention implementation; Knowledge translation; Pain assessment; Pain intensity; Pain management; Pediatric pain; Procedural pain; Quality improvement; Tailored intervention
references.citation: American Academy of Pediatrics Committee on Fetus and Newborn, Section on Surgery, and Section on Anesthesiology and Pain Medicine, Canadian Pediatric Society Fetus and Newborn Committee. Prevention and management of pain in the neonate: an update. Pediatrics 2006;118:2231-2241.
references.citation: American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001;108:793-797.
references.citation: Bartocci M, Bergqvist LL, Lagercrantz H, Anand KJ. Pain activates cortical areas in the preterm newborn, brain. PAIN® 2006;122:109-117.
references.citation: Cosby RH, Howard M, Kaczorowski J, Willan AR, Sellors JW. Randomizing patients by family practice: sample size estimation intracluster correlation and data analysis. Fam Pract 2003;20:77-82.
references.citation: Cummings GG, Estabrooks CA, Midodzi W, Wallin L, Hayduk L. Influence of organizational characteristics and context on research utilization. Nurs Res 2007;56:S24-S29.
references.citation: Cummings GG, Hutchinson AM, Scott SD, Norton PG, Estabrooks CA. The relationship between characteristics of context and research utilization in a pediatric setting. BMC Health Serv Res 2010;10:168.
references.citation: Dufault MA, Sullivan M. A collaborative research utilization approach to evaluate the effects of pain management standards on patient outcomes. J Prof Nurs 2000;16:240-250.
references.citation: Ellis JA, Sharp D, Newhook K, Cohen J. Selling comfort: a survey of interventions for needle procedures in a pediatric hospital. Pain Manag Nurs 2004;5:144-152.
references.citation: Estabrooks CA, Floyd JA, Scott-Findlay S, O'Leary K, Gushta M. Individual determinants of research utilization: a systematic review. J Adv Nurs 2003;43:506-520.
references.citation: Estabrooks CA, Scott-Findlay S, Squires JE, Stevens B, O'Brien-Pallas L, Watt-Watson J, Profetto-McGrath J, McGilton K, Golden-Biddle K, Lander J, Donner G, Boschma G, Humphrey CK, Williams J. Patterns of research utilization on patient care units. Implement Sci 2008;3:31.
references.citation: Estabrooks CA, Squires JE, Hutchinson AM, Scott S, Cummings GG, Kang SH, Midodzi WK, Stevens B. Assessment of variation in the Alberta Context Tool: the contribution of unit level contextual factors and practice specialty in Canadian pediatric acute care settings. BMC Health Serv Res 2011;11:251.
references.citation: Funk SG, Champagne MT, Wiese RA, Tornquist EM. Barriers to using research findings in practice: the clinician's perspective. Appl Nurs Res 1991;4:90-95.
references.citation: Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, Vale L. Toward evidence-based quality improvement: evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med 2006;21:S14-S20.
references.citation: Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman A, O'Brien MA. Changing provider behavior: an overview of systematic reviews of interventions. Med Care 2001;39:II2-II45.
references.citation: Hart CWM. The Hawthorne experiments. Can J Econ Polit Sci 1943;9:150-163.
references.citation: Heish FY. Sample size formulae for intervention studies with cluster as the unit of randomization. Stat Med 1988;8:1195-1201.
references.citation: Helgadottir HL. Pain management practices in children after surgery. J Pediatr Nur 2000;15:334-340.
references.citation: Hicks C, von Baeyer C, Spafford P, van Korlaar I, Goodenough B. The faces pain scale-revised: toward a common metric in pediatric pain, measurement. PAIN® 2001;93:173-183.
references.citation: Hoffman DL, Sadosky A, Dukes EM, Alvir J. How do changes in pain severity levels correspond to changes in health status and function in patients with painful diabetic peripheral neuropathy? PAIN® 2010;149:194-201.
references.citation: Holsti L, Grunau RE, Oberlander TF, Osiovich H. Is it painful or not? Discriminant validity of the Behavioral Indicators of Infant Pain (BIIP) Scale. Clin J Pain 2008;24:83-88.
references.citation: Holsti L, Grunau RE. Initial validation of the Behavioral Indicators of Infant Pain (BIIP). PAIN® 2007;132:264-272.
references.citation: Hubbard AE, Ahern J, Fleischer NL, Van der Laan M, Lippman SA, Jewell N, Bruckner T, Satariano WA. To GEE or not to GEE: comparing population average and mixed models for estimating the associations between neighborhood risk factors and health. Epidemiology 2010;21:467-474.
references.citation: Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six, methods. PAIN® 1986;27:117-126.
references.citation: Johnston C, Barrington KJ, Taddio A, Carbajal R, Filion F. Pain in Canadian NICUs: have we improved over the past 12 years? Clin J Pain 2011;27:225-232.
references.citation: Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care 1998;7:149-158.
references.citation: Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Sci 2008;3:1-12.
references.citation: Lacey EA. Research utilization in nursing practice: a pilot study. J Adv Nurs 1994;19:987-995.
references.citation: Lee SK, Aziz K, Singhal N, Cronin CM, James A, Lee DS, Matthew D, Ohlsson A, Sankaran K, Seshia M, Synnes A, Walker R, Whyte R, Langley J, MacNab YC, Stevens B, von Dadelszen P. Improving the quality of care for infants: a cluster randomized controlled trial. CMAJ 2009;181:469-476.
references.citation: Luck J, Peabody JW, Dresselhaus TR, Lee M, Glassman P. How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record. Am J Med 2000;108:642-649.
references.citation: McCormack B, Kitson A, Harvey G, Rycroft-Malone J, Titchen A, Seers K. Getting evidence into practice: the meaning of context. J Adv Nurs 2002;38:94-104.
references.citation: Merkel SI, Voepel-Lewis T, Shayevitz JR, The Malviya.S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293-297.
references.citation: Pettengill MM, Gillies DA, Clark CC. Factors encouraging and discouraging the use of nursing research findings. Image: J Nurs Scholarsh 1994;26:143-147.
references.citation: Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies: a synthesis of systematic review findings. J Eval Clin Pract 2008;14:888-897.
references.citation: Ramelet AS, Rees NW, McDonald S, Bulsara MK, Huijer Abu-Saad H. Clinical validation of the Multidimensional Assessment of Pain Scale. Pediatr Anaesth 2007;17:1156-1165.
references.citation: Rodgers S. An exploratory study of research utilization by nurses in general medical and surgical wards. J Adv Nurs 1994;20:904-911.
references.citation: Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B, Titchen A. An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs 2004;13:913-924.
references.citation: Scott P, Ansell B, Huskisson E. Measurement of pain in juvenile chronic polyarthritis. Ann Rheum Dis 1977;36:186-187.
references.citation: Slater R, Cantarella A, Gallella S, Worley A, Boyd S, Meek J, Fitzgerald M. Cortical pain responses in human infants. J Neurosci 2006;26:3662-3666.
references.citation: Stevens B, Johnston C, Petryshen P, Taddio A. Premature infant pain profile: development and initial validation. Clin J Pain 1996;12:13-22.
references.citation: Stevens B, McGrath P, Yamada J, Gibbins S, Beyene J, Breau L, Camfield C, Finley A, Franck L, Howlett A, Johnston C, McKeever P, O'Brien K, Ohlsson A. Identification of pain indicators for infants at risk for neurological impairment: a Delphi consensus study. BMC Pediatr 2006;6:1.
references.citation: Stevens BJ, Abbott LK, Yamada J, Harrison D, Stinson J, Taddio A, Barwick M, Latimer M, Scott SD, Rashotte J, Campbell F, Finley GA. CIHR Team in Children's Pain. Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ 2011;183:E403-E410.
references.citation: Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, Stinson J, Le May S. CIHR Team in Children's Pain. Pain assessment and pain intensity of children in Canadian pediatric hospitals. J Pain 2012;13:857-865.
references.citation: Taddio A, Chambers CT, Halperin SA, Ipp M, Lockett D, Rieder MJ, Shah V. Inadequate pain management during childhood immunizations: the nerve of it. Clin Ther 2009;31:S152-S167.
references.citation: Taljaard M, Donner A, Villar J, Wojdyla D, Velazco A, Bataglia V, Faundes A, Langer A, Narváez A, Valladares E, Carroli G, Zavaleta N, Shah A, Campodónico L, Romero M, Reynoso S, de Pádua KS, Giordano D, Kublickas M, Acosta A, Bataglia V. World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Intracluster correlation coefficients from the WHO Global Survey on Maternal and Perinatal Health: implications for implementation research. Paediatr Perinat Epidemiol 2005;2008:117-125.
references.citation: Taylor EM, Boyer K, Campbell FA. Pain in hospitalized children: a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manag 2008;13:25-32.
references.citation: Voepl-Lewis T, Burke CN, Jeffreys N, Malviya S, Tait AR. Do 0–10 numeric rating scores translate into clinically meaningful pain measures for children? Anesth Analg 2011;112:415-421.
references.citation: Yamada J, Stinson J, Lamba J, Dickson A, McGrath PJ, Stevens B. A review of systematic reviews on pain interventions in hospitalized infants. Pain Res Manag 2008;13:413-420.