Pediatric Pain Assessment in the Intensive Care Unit: An Evidence-Based Algorithm.

BACKGROUND: Conducting an adequate pain assessment in the Pediatric Intensive Care Unit (PICU) is multifactorial and complex due to the diversity of the population. It is critical that validated pain assessment methods are used appropriately and consistently to aid in evaluation of pain and pain management interventions. PURPOSE: The aim of this evidence-based practice project was to improve pain assessment practices in the PICU through a decision-support algorithm. DESIGN & METHODS: The Iowa Model-Revised was used to guide the development and implementation of an evidence-based decision algorithm. Pre- and postdata were collected via surveys (nursing knowledge and confidence) and documentation audits (nursing pain assessments). Various implementation strategies were used to facilitate the integration and sustainability of the algorithm in practice. RESULTS: The majority of survey items showed an increase in nursing knowledge and confidence. Audits of pain assessment documentation displayed an increase in appropriate pain assessment documentation related to a child's communicative ability. However, there is a need for reinfusion related to the documentation of sedation assessments. CONCLUSIONS: The use of an algorithm supported the ability of PICU nurses to critically consider and choose the pain assessment method most appropriate for the patient's condition. The algorithm promotes nursing clinical judgement, prioritizes pain management, and includes patients receiving sedation. The algorithm supports a comprehensive pain assessment in a difficult pediatric patient population. Future research is needed to strengthen and standardize the usage of terms "assume pain present" and "assume pain managed," and to also improve the overall feasibility and effectiveness of the algorithm.

Pain management prior to nasogastric tube placement: atomized lidocaine.

Nasogastric tube (NGT) insertion is often painful for patients of all ages. Randomized clinical trials in adult patients support the use of some form of topical lidocaine in reducing pain associated with NGT insertion. A review of pediatric evidence also confirms that NGT insertion is painful and provides guidance in determining lidocaine concentrations, dosages, and administration methods. The Iowa Model of Evidence-Based-Practice to Promote Quality Care provided the framework for development of a weight-based standard of practice (SOP) for administration of atomized lidocaine prior to NGT insertion for all patients. To facilitate usage, the orders for NGT placement and atomized lidocaine administration were linked in the electronic health record (EHR). Atomized lidocaine was administered via a patient-specific intranasal mucosal delivery device. Evaluation measures included pre- and post-implementation questionnaires which measured discomfort with NGT insertion in pediatric patients (0-10 scale; pre-implementation mean = 7.4; post-implementation mean = 6.5), monitoring utilization of atomized lidocaine via automated dispensing cabinet reports, soliciting comments from families and users, and monitoring institutional patient safety (incident) and adverse drug reaction reports. No patient safety or adverse drug reactions related to atomized lidocaine were identified post-implementation. Patients of all ages have benefited from administration of weight-based intranasal atomized lidocaine to decrease pain caused by NGT insertion. Ongoing safety evaluation and research is warranted since this is the first known report in the literature describing implementation of a weight-based dosing SOP.