Lessons learned from piloting a pain assessment program for high frequency emergency department users.

Background and aims Chronic pain (CP) management presents a challenge for the healthcare system as many individuals experiencing CP cannot access appropriate services. Consequently, individuals may visit emergency departments (EDs) to address their CP, even though this setting is not the most appropriate. CP was identified as a common factor amongst patients with repeat ED use at a hospital in Ottawa, Canada. Thus, staff of the Pain Clinic developed the Rapid Interdisciplinary Pain Assessment Program to improve the care of patients with CP who had a minimum of 12 ED visits in the previous year, who were considered high frequency users (HFUs) of the ED. This evaluation was conducted to guide program improvements in advance of a clinical trial. The results are reported here in order to describe lessons that could be applied to the development of similar programs. The benefits of the program in reducing ED use, pain intensity, disability, and psychological distress have been described elsewhere (Rash JA et al. Pain Res Manag 2018:1875967). Methods Thirty-five people completed semi-structured interviews or a focus group, including eight patients, six ED staff, four primary care physicians (PCP), five Pain Clinic physicians, and 12 program staff members. Questions focused on the program's implementation, as well as strengths and areas for improvement. Results The program was generally consistent in offering the intended patients the services that were planned. Specifically, patients received an interdisciplinary assessment that informed the development of an assessment and treatment plan. These plans were shared with the PCP and added to the patient's hospital electronic medical record. Patients also received education about CP and had access to medical pain management, substance use, and psychological treatments. Inter-professional communication was facilitated by case conferences. Numerous aspects of the program were perceived as helpful, such as the quick access to services, the comprehensive assessment and treatment plans, the individualized treatment, the use of an interdisciplinary approach to care, and the communication and relationships with other care providers. However, challenges arose with respect to the coordination of services, the addition of supplementary services, the accessibility of the program, patients' perceptions of being misunderstood, communication, and relationship-building with other service providers. Conclusions The program sought to improve the care of HFUs with CP and reduce their ED use for CP management. The program had numerous strengths, but also encountered challenges. Developers of programs for HFUs with CP are encouraged to consider these challenges and suggested solutions. These programs have the potential to deliver effective healthcare to individuals with CP and reduce ED overutilization. Implications Our findings suggest that the following points should be considered in the development of similar programs: the inclusion of a case manager; the use of strategies to ensure inter-professional communication, such as secure electronic consultation, approaches to allow access to assessment and treatment plans, and offering a range of modalities for communication; holding regular case conferences; determining the appropriate types of services to offer; and working to address patients' fears of being labelled.

Thinking ahead about where something is needed: new insights about episodic foresight in preschoolers.

We explored 3-, 4-, and 5-year-olds' capacity to draw on a past experience that entailed the lack of a particular resource (in this case, toys) in one room, but not in another, to make an adaptive choice (i.e., place toys in the room where there were none) for a subsequent visit to the two rooms. Children's memory for which room had toys and which room did not was explicitly assessed. Children were then queried about where they should place a new set of toys for their next visit to the rooms. In Experiment 1, where children were asked about the "distant" future, 4- and 5-year-olds, but not 3-year-olds, placed the toys in the "no-toy" room at a rate significantly higher than chance. In Experiment 2, where children were asked about the "immediate" future, correct responses of 3-year-olds were still no different from chance, those of 5-year-olds were above chance, and those of 4-year-olds trended in this direction. Our discussion centers on the importance of assessing both "memory" and "foresight" on tasks purported to assess children's episodic foresight, the role of "temporal distance" on children's future-oriented behavior, and implications for future research.