Procedural pain assessment in infants and young children: identifying a suitable behavioural assessment scale

© 2018 Dr Dianne CrellinInfants and young children frequently experience pain as a consequence of medical procedures associated with their healthcare. Pain management is often suboptimal, and this is in part due to the difficulties associated with assessment of pain of infants and children too young to self-report pain intensity. Observable behaviours indicative of pain have long been considered a viable alternative and scales comprised of these behaviours have proliferated in the literature. However, it remains unclear which scales are best suited for procedural pain assessment and whether they are well supported by psychometric data. The aims of this project were to: identify behavioural observation scales potentially suitable for procedural pain assessment, summarise available psychometric data and prospectively test the psychometric properties of potentially suitable scales when used to assess procedural pain in infants and young children. These aims were addressed in three phases of work: i) a thorough interrogation of the literature to identify scales considered potentially suitable for assessing procedural pain in infants and children, ii) a series of systematic reviews to summarise the evidence supporting the psychometric properties of the identified scales and iii) a prospective observational study to test the psychometric properties of these scales used to assess procedural pain in infants and young children. Three scales, the Face, Legs, Activity, Cry and Consolability Scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs), met predefined criteria and were considered potentially suitable for inclusion in this project. The systematic reviews showed that available psychometric data was insufficient to recommend these scales for procedural pain assessment of infants and children. There was data to tentatively support the MBPS and to a lesser extent the VASobs for assessing immunisation related pain. The data regarding the FLACC scale was inconclusive. The results of the prospective study confirmed that all scales were sensitive to pain. The FLACC scale and MBPS scores were reliable (intraclass correlation (ICC) 0.92 and 0.87, respectively) but VASobs scores were less reliable (ICC 0.55). The FLACC scores showed the highest sensitivity (94.9%) and specificity (72.5%) for procedure type (painful vs non-painful) at the lowest cut-off score (pain score 2, area under the curve (AUC 0.83)). Similar results were achieved at a MBPS cut-off score of 4 (sensitivity 91.5%, specificity 77.5%, AUC 0.85). The FLACC scale resulted in more incomplete scores (p < 0.000) and was changed more often than other scale scores. Reviewers liked the VASobs most, considered it the quickest and easiest to apply, but judged the FLACC scale and MBPS to be more likely to be useful. In conclusion, three behavioural observational pain scales to assess procedural pain in infants and young children were identified and included in systematic reviews. This work culminated in a prospective study, the results of which support use of the FLACC scale, but not without reservation as there are practical limitations when used to assess procedural pain. These results build on promising existing evidence that suggests that the FLACC scale may currently be a suitable scale for procedural pain assessment in infants and young children

Metrics, methods and instruments used to evaluate the impact of nurse practitioner roles: A scoping review protocol

Objective: The objective of this scoping review is to identify what metrics, methods and instruments are used to evaluate the impact of nurse practitioner roles. Introduction: There is much literature evaluating the impact of the nurse practitioner (NP) roles on processes and outcomes of care. Most of this literature evaluates highly specialised areas of NP practice rather than focusing on core elements of these roles. There is a critical need to clearly demonstrate the contribution of NP roles to the healthcare system and to the health of the population. To evaluate NP impact common to all roles, it is important to scope the available evidence to identify current metrics, methods, and instruments. By undertaking this review, we expect to establish an evidence base for the development of a core set of indicators sensitive to all NP models. Inclusion criteria: Articles exploring any form of NP service process outcomes will be included. Articles that report on outcomes of advanced practice nursing roles will be included if it is possible to extrapolate NP specific outcomes. Any healthcare service and area of specialty nurse practitioner practice will also be included. Methods: The proposed scoping review will be guided by the JBI methodology for scoping reviews. Peer review of quantitative, qualitative and mix method research articles in English will be performed. Medline, Cumulative Index to Nursing and Allied Health, Embase, and Scopus electronic databases will be searched. Screening of identified citations will be reviewed by a single reviewer following intra-rater reliability of 10% of citations at each stage. Data extraction will be performed using two reviewers. Results: The results of the search will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) flow diagram, and a narrative summary to explain how the results relate to the review questions and objectives. Implications: Key findings from this review will be used to develop research questions and inform evaluations of the impact of NP roles on health systems and health outcomes. The results will be disseminated though peer-reviewed publication and conference presentations

Prevention of pulmonary complications in the adult patient recieving mechanical ventilation in the emergency department: a scoping review

The objective of this scoping review is to summarise the evidence regarding the prevention of pulmonary complications in adult patients receiving mechanical ventilation in the emergency departmen

Can simple mobile phone applications provide reliable counts of respiratory rates in sick infants and children? An initial evaluation of three new applications

BACKGROUND: Respiratory rate is an important sign that is commonly either not recorded or recorded incorrectly. Mobile phone ownership is increasing even in resource-poor settings. Phone applications may improve the accuracy and ease of counting of respiratory rates. OBJECTIVES: The study assessed the reliability and initial users\u27 impressions of four mobile phone respiratory timer approaches, compared to a 60-second count by the same participants. METHODS: Three mobile applications (applying four different counting approaches plus a standard 60-second count) were created using the Java Mobile Edition and tested on Nokia C1-01 phones. Apart from the 60-second timer application, the others included a counter based on the time for ten breaths, and three based on the time interval between breaths (\u27Once-per-Breath\u27, in which the user presses for each breath and the application calculates the rate after 10 or 20 breaths, or after 60s). Nursing and physiotherapy students used the applications to count respiratory rates in a set of brief video recordings of children with different respiratory illnesses. Limits of agreement (compared to the same participant\u27s standard 60-second count), intra-class correlation coefficients and standard errors of measurement were calculated to compare the reliability of the four approaches, and a usability questionnaire was completed by the participants. RESULTS: There was considerable variation in the counts, with large components of the variation related to the participants and the videos, as well as the methods. None of the methods was entirely reliable, with no limits of agreement better than -10 to +9 breaths/min. Some of the methods were superior to the others, with ICCs from 0.24 to 0.92. By ICC the Once-per-Breath 60-second count and the Once-per-Breath 20-breath count were the most consistent, better even than the 60-second count by the participants. The 10-breath approaches performed least well. Users\u27 initial impressions were positive, with little difference between the applications found. CONCLUSIONS: This study provides evidence that applications running on simple phones can be used to count respiratory rates in children. The Once-per-Breath methods are the most reliable, outperforming the 60-second count. For children with raised respiratory rates the 20-breath version of the Once-per-Breath method is faster, so it is a more suitable option where health workers are under time pressure

National nursing registration in Australia : a way forward for nurse practitioner endorsement

Purpose : The move to national registration of health professionals and the creation of the Nursing and Midwifery Board of Australia (NMBA) provides both challenges and opportunities for the regulation of nurse practitioners (NPs) in Australia.Data sources : National and state health policy documents, accessible on the Internet, concerning the regulation and endorsement processes for NPs in Australia were examined.Conclusions : The similarities between two of the previous jurisdictional NP endorsement processes in New South Wales and Victoria provide a common ground on which to build a robust national system. However, there are also key differences between these two states. These differences were mainly in the evidence required to assess competency of NP applicants and the authority to prescribe medications. All Victorian NP applicants were required to complete an approved medication subject at a master\u27s level.Implications for practice : A consistent endorsement process that delivers NPs of the highest standard and allows for efficient use of their skills and expertise is vital. This needs to be performed with the aim of providing high-quality care in a regulatory environment that protects the public and clearly articulates the level of competence expected of all NPs

16 The ultimate interface and the sums of life?

www.bcs-hci.org.uk Fifty issues of Interfaces and 16 years later – how much has changed

Barriers and Co-Designed Strategies for the Implementation of Negative Pressure Wound Therapy in Acute Paediatric Burn Care in Australia: A Mixed Method Study

BackgroundPaediatric burn injuries pose a major clinical problem worldwide and result in significant morbidity. Early adjunctive application of negative pressure wound therapy (NPWT) significantly improves time to healing by re-epithelialisation in children with burns. This treatment strategy has not been consistently adopted as part of acute paediatric burn care.MethodsThis investigation used a sequential mixed methods design to identify and explore barriers to the implementation of adjunctive NPWT in acute paediatric burn care. An online questionnaire was developed and disseminated to healthcare professionals within four major paediatric hospitals in Australia, each with a dedicated burns service. Specific barrier data were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews were then conducted with senior clinicians across the four participating hospitals to tailor implementation strategies to local contexts. A stakeholder consensus meeting was then conducted to consolidate implementation strategies and local processes.ResultsA total of 63 healthcare professionals participated in the online questionnaire, and semi-structured interviews were conducted with nine senior burn clinicians. Two interviews were also conducted with parents and caregivers of paediatric burn patients who had received adjunctive NPWT as part of their acute burn treatment within the last 12-months. This investigation identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address these identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change (which describes clinicians’ readiness or enthusiasm to change practice), patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies and incentives, intervention complexity, and poor planning of the intervention implementation.ConclusionThere are multiple and inter-related contextual characteristics that influence the uptake of adjunctive NPWT into acute paediatric burn settings in Australia. Results from this investigation will be used within a multi-state stepped-wedge cluster randomised controlled trial. In order to implement adjunctive NPWT into clinical practice for the acute treatment of paediatric burn injuries, additional resources, education, training, and updates to policies and guidelines are required. It is anticipated that adjunctive NPWT, in conjunction with tailored implementation strategies, will enhance adoption and sustainability.Trial RegistrationThis trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR) on the 1st of February 2022 – registration number ACTRN12622000166774

Barriers and co-designed strategies for the implementation of negative pressure wound therapy in acute pediatric burn care in Australia: A mixed method study

PurposePediatric burn injuries are a global clinical issue causing significant morbidity. Early adjunctive negative pressure wound therapy improves re-epithelialization rates in children with burns, yet adoption in acute burn care is inconsistent. This investigation aimed to determine barriers to the implementation of adjunctive negative pressure wound therapy for the acute management of pediatric burns and co-design targeted implementation strategies.MethodsA sequential mixed methods design was used explore barriers to adjunctive negative pressure wound therapy implementation in acute pediatric burn care. An online questionnaire was disseminated to healthcare professionals within four major Australian pediatric hospitals, each with a dedicated burns service. Barriers were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews with senior clinicians tailored implementation strategies to local contexts. A stakeholder consensus meeting consolidated implementation strategies and local processes.ResultsSixty-three healthcare professionals participated in the questionnaire, and semi-structured interviews involved nine senior burn clinicians. We identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change, patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies, intervention complexity, and poor implementation planning.ConclusionMultiple contextual factors affect negative pressure wound therapy uptake in acute pediatric burn settings. Results will inform a multi-state stepped-wedge cluster randomized controlled trial. Additional resources, education, training, updated policies, and guidelines are required for successful implementation. It is anticipated that adjunctive negative pressure wound therapy, in conjunction with tailored implementation strategies, will enhance adoption and sustainability.Trial registrationAustralian and New Zealand Clinical Trials Registry: ACTRN12622000166774. Registered 1 February 2022