Communication Th e health care professionals should communicate with each other on a regula r basis both about individual patients and the programs which are o \200 ered in the pain treatment facility Have established protocols for patient management and assess their e \203 cacy periodically Sta \203 ng essentials Sta \200 can include physicians, nurses, psychologists, physical t herapists, occupational therapists, vocational counselors, social workers, and neurologists Director/Coordinator who will be responsible for monitoring of the medical services provid ed Administrative/Support sta \200 to maintain records on patients for assessment of indiv idual treatment outcomes and evaluation of overall program e \200 ectiveness, also to carr y out additional activities Medically trained professional available to deal with patient r eferrals and emergencies Services Diagnostic and therapeutic services which include medication management, referral for appropriate medical consultation, review of prior medical records and diagnostic tests, physical examination, psychological assessment and treatment, physical therapy, vocational assessment and counseling, and other facilities as appropriate Facilities for inpatient se rvices and outpatient services should be present Research characteristics for a center Carry out research on chronic pain. All providers do not have to do both research and patient care but the institution should have ongoing resea rch activities Actively engage in educational programs for a wide variety of health care pr oviders, including under-graduate, graduate, and postdoctoral levels A \203 liation with a major health sciences educational or research institution SECTION 9 special topics 644 to avoid the cost of inpatient care (Weisman, 2008). Th ere are a variety of terms used to describe multidisciplinary facilities, but the main distinctions lie between multimodal, in terdisciplinary, and multidisciplinary. Multimodal treatment refers to the simultane- ous a pplication of separate and complementary therapeutic inter- vention performed under the sup ervision of a single practitioner (American Society of Anesthesiologists, 2010). Th e disti nction between interdisciplinary and multidisciplinary treatments is less distinct. Traditi onally multidisciplinary approaches have been used to describe a plan with more than one pr ovider (usually medical specialists) delivering care without direct communication or col- l aboration with the other providers, and not necessarily in the same location. An interdisci plinary approach coordinates the providers in one setting (usually including several distin ct disciplines includ- ing medicine, nursing, psychology, physiotherapy, etc.) so that they work together in an integrated manner and develop joint goals with the patient (Rudin, 200 1). Recently, the term multidisciplinary has been used in the research literature, as an um brella term that refers to both inter-and multidisciplinary approaches (Ospina and Harstall , 2003). Th is chapter will employ the term multidisciplinary pain care (MPC) to refer to t he ideal setting of an interdisciplinary coordinated approach either in a pain clinic or a pain center. Box 62.1 Recommended established procedures for acute care models 1. The documentation of the pain history of patient, including: typical pain related behavi ors, and the child \200\231s description of the pain. 2. Systematic assessment and recording of pain and all related symptoms. 3. Pharmacological management. 4. Cognitive-behavioral management. 5. Strategies to prevent pain and other symptoms. 6. Management of side effects of treatment. 7. Monitoring of pain, vital signs, and level of consciousness. 8. Ensure that all specialized services and techniques provided throughout health center ar e available for treatment includ- ing: patient controlled analgesia, epidural infusions, pa tient controlled epidural analgesia, subarachnoid infusions, plexus infusions, implantable baclofen pumps. 9. Education and training programs. Th e International Association for the Study of Pain (IASP) has stated that there is signif i cant evidence for the eff ectiveness of multidisciplinary treatment for chronic pain. Th e Canadian Pain Society (CPS) has stated the need to include both physical and psy- chologi cal treatment elements into patient care. Th e CPS (2012) position statement states, \200 \230Pain is not just a symptom of underlying illness or injury, but it is a disease in its own right, with signifi - cant changes in complex biological, and psychological functions \200\231. Th is statement emphasizes the requirement to treat pain symptoms holistically, u sing a variety of providers. management improves outcomes, but many pediatric health prac- titioners agree that these ar e key features to be included in any acute pain service (American Society of Anesthesiologi sts, 2010). Th ere is also strong agreement that in light of their expertise and training, anaesthesiologists should be involved, along with other health care providers, in the estab lishment of all acute pain guidelines, treat- ment standards and practices. Th e acute pain service is a model in which a recognized group of health care providers (ph ysicians, nurses, and pharmacists) are responsible for the development of standards for pai n assess- ment and management throughout the health center. Th ere is evi- dence that this type of service model provides more prompt care (Miaskowski et al., 1999). Th is group has as its primary goal the delivery of hands on care and symptom management on a daily basis f or a specifi c cohort of patients (Berde and Solodiuk, 2003). Advantages of this approach a re that there is a dedicated team that have pain management as their sole focus not as a se condary goal. Th e team has expertise and a commitment to be eff ective and over time their experience grows and they will become a better team, able to handle a variety of situation s and possible complications. Th ere is also the potential institutional advantage of a tea m that the rest of the health center can quickly contact when needed. Th is group is positi oned to implement quality assurance strategies which contribute to improved care. Disadvant ages of this model include possible inhibition of a more general development of health prov id- ers \200\231 skill beyond basic acute pain management. Providers should be aware that t his may happen and develop ways to ensure professional development. In order to keep pace w ith innovations in other fi elds (new procedures, surgical techniques etc.), the pain servi ce team should develop communication links with departments throughout the health center. F inally, there are increased costs associated with developing a specifi c pain service. It m ay be diffi cult to fi nancially justify creating a team of skilled providers for the sole purpose of acute pain treatment (Berde and Solodiuk, 2003). Acute pain services Acute pain services need to be available 24 h a day, 7 days a week. Ser vices may be centralized as a formal acute pain service within a health care setting (i.e. hospital), or can be provided by surgical staff , hospitalists, and ward nurses. Either mod el could provide excellent care. Th e choice will be aff ected by the local situation (pres ence of trained and interested anaesthesiologists and nurses, acceptance by surgeons and wa rd nurses). Whichever model is used, there should be access to the range of strategies and techniques as described in Box 62.1 . Institutional procedures should be established for education and training, monitoring of pa tient outcomes, documentation, and institutional monitoring of activities, and availability of service providers (anaesthesiologists, appropriately trained nursing staff or physician assistants). Observational studies have found that education and training programs for hea lth care providers in pain care are correlated with lower pain levels, decreased nausea, an d increased patient satisfaction (Coleman and Booker-Milburn, 1996; Harmer and Davies, 1998 ). Educational programs should include content ranging from basic bedside pain assessment t o sophisticated pain management techniques, and non-pharmaco- logical interventions. Compre hensive training programs for all new personnel are required. Th ere is limited evidence to suggest that monitoring of outcomes and the availability of a naesthesiologists for specialty care in pain CHAPTER 62 organizational systems in pediatric pain 645 Th e alternative to having an acute pain service model is to have primary care or health ce nter practice standards with educational support. In this setting pain management is implem ented by the individual services using standards set by a multidisciplinary com- mittee. St andards are for both assessment and analgesia. Regular education programs are oft en provid ed in this setting (Berde and Solodiuk, 2003). Th ere are several advantages to this approa ch but implementation requires widespread education and training. It \200\230empowers \200 \231 providers practicing throughout the health center, intimately familiar with their pati ents who can evaluate pain and other symptoms within the context of their overall managemen t. Costs are oft en lower than in the acute pain service model. A disadvantage is that acut e pain care is no one \200\231s primary respon- sibility; providers may be more preoccupied with other aspects of treatment and overlook pain management. It may be unrealistic to exp ect busy clinicians to continually train and educate them- selves on best practices in acut e pain management; therefore there is a risk that treatment may not be optimal. Th ere may be more delays in this type of treatment environment, oft en due to com- peting tasks. Fina lly, there may be less intensive monitoring and feedback about treatment, therefore subopti mal practices may not be identifi ed and rectifi ed. Th ere is less risk that losing one or two key providers (advanced practice pain nurses, for example) will disable an entire serv ice, but it takes longer to get all staff up to a high level of performance. and Weisman, 2000; Th e Royal Australasian College of Physicians, 2006). Th e majority of t hese procedures should be available when needed. Organization of staff scheduling should be ar in mind the training of available staff during each shift to maintain the avail- ability of these procedures to be performed by highly skilled and trained staff . Several of the m ethods require more than one trained professional on hand; availability of such a person sh ould be ensured. Training and education about these techniques should be routine in pain ma nagement centers. Chronic pain management Pediatric chronic pain has a signifi cant impact on social, emo- ti onal, psychological, mental, and spiritual components of the life of a child and their fami ly. Th e biopsychosocial model of pain pro- vides the essential theoretical framework withi n which to establish a treatment program. Delivery of care in all three areas must be provi ded by the organizational structure. Th ree key features of the insidious development of pain from fi rst occurrence to life cha nging condition have been described: impair- ment, disability, and handicap (Desparmet, 200 9). Impairment is when the pain fi rst surfaces and begins a cycle of pain \200\223inactivi ty \200\223 more pain \200\223more inactivity. Th is leads to disability , when a child is unable to physically participate in age-appropriate daily activi- ties. Parents oft en iden tify behavior changes and absenteeism from school and other structured activities. Th e phy sical separa- tion from family and peers is accompanied by emotional isola- tion. Th ese ps ychological and mental consequences oft en lead to handicap , characterized by sleep distur bance, further emotional withdrawal, and expressions of hopelessness. Th is may severely li mit the normal development of the child. As described, chronic pain has signifi cant far re aching negative repercussions on the child \200\231s life. Th erefore treatment must addres s all of these concerns and should be a priority for the family. Early intervention, with t he aim of limiting the duration or extent of disability, will hopefully prevent major impai rment. Th e objective of a pain management program may in fact be a return to normal functi oning, and not resolution of pain symptoms. Paradoxically, return to function can oft en le ad to reduction in pain (Desparmet, 2009). Preoperative preparation By reducing the anxiety and distress associated with many commonly performed surgical procedures, long-term treatment outcomes can be improved (Golianu et al ., 2000).Preoperative assessment and consultation around analgesic management can signifi c ant alleviate some symptoms of postoperative pain and are critical to pain man- agement (Am erican Society of Anesthesiologists, 2010). Th e MPC team will discuss with the child and f amily issues related to the sur- gical procedure, pain and expected treatment options inclu ding: expected severity of postoperative pain, pre-existing medical con- ditions, risk \200 \223benefi t of the treatments under consideration, previ- ous experiences with pain, and p atient preferences. Preoperative establishment of a pain management protocol is associated with less overall analgesic use, shorter time to extubation, and shorter times to discharge (Susan et al., 1998). Before patients enter a Pediatric Pain Center (PPC) they have oft en visited a variety of o ther specialists over a period of 4 to 6 months and have not observed substantive positive results. Th is fragmentation of care exacerbates the disability process (Desparmet, 2009). Additionally the family is oft en required to restructure their daily routine and possibly their employment patterns. Th is disrupts the life of both the patient and their familial s upport system. Preparation of the patient includes continuation of usual medica- tions (preventing abstine nce syndrome) and premedication needed for the surgery. Educational sessions for the patien t and family can include behavioral pain control techniques. Although it is sug- gested tha t most of the MPC team, especially the anaesthesiologist, be present during the educational components (American Society of Anesthesiologists, 2012), for practical purposes much of t he trans- mission of information is frequently carried out by child life provid- ers or oth er professionals, while the anaesthesiologist will provide their input in the context of th e preoperative anesthesia assessment. Patient and parent roles in interpreting postoperativ e pain should be established before surgery. Th is will support achieving comfort, reportin g of abnormal pain patterns and proper use of analgesics. Th is pediatric MPC includes the composition of the health pro- vider team and their indivi dual and cumulative backgrounds as essential in developing a MPC team. Furthermore their co nsistent communication and progressive development is highlighted as a key to success. Pedi atric chronic pain is positioned as a biopsycho- social phenomenon that requires the involv ement of patient, their family, their social support, and the experiences, attitudes, and b eliefs that they bring to the assessment period and through treat- ment. Th e expressed sym ptoms and biological determinants are considered in conjunction with medical guidelines and pathology and incorporated into the framework of the social and psychologi- cal characteri stics of the family and patient. Mental health history, lifestyle, education, social patter ns, stressors, and any related family Facilities and equipment for acute pain interventions Table 62.2 details procedures and the ir associated equipment and staffi ng needs (Brislin and Rose, 2005; Golianu et al., 2000; Rusy SECTION 9 special topics 646 Table 62.2 Techniques and equipment for acute pain services Technique Personnel Equipment Distraction Any health professional or family member Materials that can capture and maintain a child \200\231s attention Kaleidoscope Stories Bu bbles Counting Pop-up toys Video games Deep breathing/muscle relaxation Physical therapist, psychologist, nurse, or family member with some education on the proces s None Self-regulation Nurse, psychologist Biofeedback equipment Transcutaneous electric nerve stimulation unit Topical anesthesia Anaesthesiologist, nurse, or physicians able to record the process (dose, medical history) None Local in \201 ltration Anaesthesiologist, nurse, or physicians able to record the process (dose, medical history) Must be competent in CPR Smallest gauge needles required Correct drugs and dosage Peripheral nerve blocks Anaesthesiologist, nurse, or physicians able to record the process (dose, medical history) Must be competent in CPR Provider should be trained in the technique, and be familiar with it A trained assistant should be used to monitor the patient during the procedure Short-beveled needles or speci \201 c insulated needles for connection to a nerve stimulat or Correct drug dose and volume Oxygen supply Equipment for arti \201 cial ventilation Suc tion equipment De \201 brillator Cardiac resuscitation drugs. Bier block (intravenous regional anesthesia) Anaesthesiologist, nurse, or physicians able to record the process (dose, medical history) Must be competent in CPR Sta \200 should be trained and familiar with use and complication s. A trained assistant should be used to monitor the patient during the process. Tourniquet Proper drug dose and volume Resuscitation equipment Nitrous oxide (N 2 O) analgesia A separate person should be used to administer the N 2 O that is not conducting procedure. Anaesthesiologist is recommended to be present especially if there are any expected complic ations A means to separately delivery oxygen and N 2 O Resuscitation equipment Ketamine and midazolam Sta \200 should be trained and familiar with use, adverse e \200 ects and complications A trained assistant should be used to monitor the patient during the procedure Sta \200 sho uld be trained in advanced airway management Resuscitation equipment Oxygen supply Equipment for arti \201 cial ventilation Suction De \201 brillator Cardiac resuscitation drugs history should be accounted for in order to develop the treatment with highest probability of success. Incorporating at least three health providers into an extended interview with t he patient and family will allow for a variety of professional perspectives to inter- pret the family dynamics, communications patterns, and identify any potential threats that may a rise. Th e team should also determine the capacity of the family to implement treatment. Fa ctors to con- sider include: marital or fi nancial stress, school absenteeism, family accommodation, school transition, high performance demands, and relationship-oriented rejec tion or loss (Desparmet, 2009). For example there is a surprisingly high percentage of pati ents that are enrolled in demanding course loads, are extremely active in extracurricular a ctivity (sports, music, volunteerism), and have a demand placed on them to perform (Weisman , 2008). Th e focus of chronic pain treatment in MPCs is rehabilitative instead of curative. Th e te am should emphasize defi nable, operable CHAPTER 62 organizational systems in pediatric pain 647 Table 62.3 Goals for a MPC pediatric patient and their family headache, abdominal pain, myofascial pain, arthritis, back pain, complex regional pain synd rome, phantom limb pain, cancer pain, sickle cell pain, and cerebral palsy-related pain (We isman, 2008). A list of staff positions will include some or all of the fol- lowing: the Di rector, Physical therapist, Nurse, Physician(s), Anaesthesiologist, Psychologist, Pharmacis t, and Child Life Specialist. Th eir specifi c roles and skill sets have been well describe d, as well as the contribution each makes to the overall process through their individual d iscipline (Berde and Solodiuk, 2003; Cravero and Blike, 2004; Eccleston, 2001; Joseph, 2007 ; Kingsley and Porfyris, 2011; McClain, 2000; Palermo et al., 2010; Schurman and Friesen, 2 010). Each may fulfi l more than one role depending upon resources and skill sets available \200\224for example, anaesthesiologists will have a specifi c professional role but may al so serve as the pain specialist; other physicians may serve to off er services arising out of their personal skill sets or function as specialty consultants (e.g. neurology, physical medicine, surgery, neurosurgery, psychiatry). No matter which medical or other pro- fessio nals are involved in the care however, the most important overall functional issue is manag ement of the communication process, as described next. Symptomatic improvement Improved physical function to participate in activities appropriate for age Reduce pain sensitivity and intensity Regain independence appropriate for age Family and patient master coping techniques Master self-management skills appropriate for age Restore individual and family productivity to a satisfactory level Decrease inappropriate use of health care system and realistic outcomes for the patient, rather than complete pain relief (Gardea and Gatche l, 2000). Quality of life outcomes with a focus on independence through restoration of phys ical, psycho- logical, and social functioning (Table 62.3 ) should be the goal. Th e rehabi litation plan should be developed on an individual patient basis with all team members. Th e process of a MPC is illustrated in Figure 62. 2, with further detail in the following sub sections includ- ing the staff , communication, multidisciplinary integrative assess- ment, outcomes, patient and parent expectations and experiences and follow-up are described late r in this chapter. Sta \200 communication/organizational relationships supporting practice Although the speci fi c role descriptions of the staff of a MPC team are important, they may be to some extent less relevant to the organizational systems discussion than the manner in which they relat e to one another and the programs off ered. Very little specifi c research illuminates the issue of eff ective communication Sta \200 positions and organization Th e disciplines required and services off ered by a P PC will be determined in part by the conditions being treated. Th e most commonly seen chro nic pain conditions in PPCs include Assessment of Resources Acute Pain Service Model/ Primary Care Model Pre-Operative Patient Assessment Psychological, Medical Assessment Patient History Review Collaboration and Development of Treatment Plan Entire MPC Team Patient and Family Preparation and Intervention Preoperative Pain Analgesia No Preoperative Pain No Analgesia Surgical Intervention Analgesia Anesthesia Implement Postoperative Procedures Terminate operative analgesics and anesthesia No pain requiring intervention: Reassess Condition/ Follow up Signi \201cant pain not expected by the surgical intervention Expected pain associated with intervention: Implement Plain for Pain Control Procedure/Inte rvention decided upon with client preoperatively Surgical evaluation Treat Unsatisfactory pain relief Satisfactory pain relief Optimize dosage Change drug interval, dose, route, modality, or treat side e \200ects Patient discharge/ Follow up Reassess, redevelop plan Figure 62.1 Patient \202 ow for acute care services. SECTION 9 special topics 648 amongst MPC professionals; however consistent communica- tion is essential to the success o f the MPC team (Dowden et al., 2008). Figure 62.2 also highlights communication within the MPC team. Many of the professional roles are traditionally independ- ent and training does not always emphasize multidisciplinary col- laboration. Routines, protocols, and regularly scheduled meetings should be implemented and encouraged in order to promote eff ec- tive co mmunication and practice. Nurses, because they can have varied roles, are oft en the core o f eff ective communication (Berde and Solodiuk, 2003). Nursing research examining the proce ss of incorporating research into practice has identifi ed those charac- teristics of an or ganization which will best support implementa- tion of best practice. Th is is described as the PARIHS ( \200\230Promoting Action on Research in Health Services \200\231) framework ( Rycroft - Malone, 2004). Successful implementation of best practice is best supported by: e vidence itself, context, and facilitation. Th ese three are further broken down to refl ect : evidence \200\224research evidence, clinical experience, patient experience and local dat a/information; context \200\224culture, leadership, and evaluation; and facilitation \200 \224 purpose, role, skills, and attributes. Th e organizational system thus can support thi s process by ensuring communication of local clini- cal experience and patient experience a s well as providing local data and information, by providing a culture which will support/ promote best practice, by selecting leaders who support these goals and putting in place co mmunication systems to facilitate the process, and by training personnel in the skills of f acilitation. It can be seen that these elements, while originally developed to address a so mewhat diff erent issue, are very relevant to the com- plex problems which frequently surro und management of paedi- atric patients with chronic pain. A pediatric chronic pain disorder such as \200\230functional gastroin- testinal disorder \200\231 (FGID), illustrates the importance of eff ective communication strategies. It is a ssociated with a complex com- bination of symptoms, including pain, related to biological a nd psychological processes. Th ese patients have high levels of health care utilization and incur signifi cant fi nancial costs (Schurman and Friesen, 2010). In this type of multifac eted disorder there may not be established clinical guidelines. Treatment is thus best pro- vided in a multidisciplinary setting in order to enhance outcomes and hopefully decrease l ong term health care costs. Th e success of treatments oft en depends on the integration of the recommen- dations of the full range of disciplines involved, especially when intervent ions need to be combined for these complex disorders (see Table 62.4 ). Parental expectations Unlike an adult, a child relies on the caregivers (parents) of the fa mily to make decisions about care. Th us the family must be incorporated into the care proc ess to an even greater extent than in adult pain management. As positive expectations for t reatment and recovery on the part of both patients and their families will benefi t overall outcome, it should be a goal for the MPC to ini- tially establish an optimistic attitude t owards expectations (Long and Guite, 2008). Th is can be a challenge because the MPC team i s rarely the fi rst service parents have sought for the child \200\231s pain. Prior to the visit to the MPC team, families with children suff er- ing from long-term chronic pain have low expectations for MPC (Tsao et al., 2005). Th is is oft en the result of prior disappoi ntment as previous diagnosis and treatments have failed to off er relief, which Ongoing Team Building & Communication Physiological Psychological \200 Education \200 Training \200 Experience Pharmacological \200 Education \200 Training \200 Experience Education \200 Training \200 Experience MPC - Management - Organization - Operations - Sta \200 Physician, Anesthesiologist, Nurse Psychiatrist, Psychologist, Life Counselor, Social Worker Pharmacist Biological Sociological Psychological Outcomes Multidisciplinary Integrative Assessment Communication Treatment expectations Treatment expectations Communication of Outcomes and Follow-up Expectations Attitudes Beliefs Description of Pain Experience Family Support Patient Figure 62.2 Structure and process of a MPC. CHAPTER 62 organizational systems in pediatric pain 649 Table 62.4 Examples of biopsychosocial interventions that have been combined for complex di sorders receiving information about the cause of pain, treatment options, drugs, and the eff ects o f both the pain and any underling proc- esses associated with the pain (Reid et al., 2010). Th is information is expected to be provided as written information to which they can refe r later. Th is can be very important to the parents \200\231 percep- tions of successful tr eatment, and may be linked to better adher- ence. Whenever possible MPC teams should strive to meet these expectations and be aware of any lingering patient or parent doubt. When par ents \200\231 expectations are not met, treatments of the child \200\231s psychological, ph ysical, and social state may not be perceived as completed. Th is may lead to an extended t reatment regimen or relapse of symptoms. Although it is not always the case, positive expec tations for recovery are correlated with better health out- comes (Long and Guite, 2008). Intervention Primary roles Prescription medication Pharmacist/Physician/Nurse Biofeedback assisted relaxation training Psychologist/Nurse Personalized therapy that targets: school issues, pain coping strategies, sleep hygiene Psychologist/Life Counselor/Nurse Acupuncture Physical Th erapist Massage Physical Th erapist Physical therapy Physical Th erapist/Nurse Family therapy Counselor Information management systems Many centers are moving to implement electronic medical reco rds (EMRs) which may facilitate information management pro- grammes and help the MPC to imp rove transfer of information between professionals. All clinical charts must be up to date and readily available to any member of the treatment team. Towards this goal, Computerized Clinical Decision Support Systems (CCDSS or CDSS) may promote implementation of best practi ce care. Th is is somewhat complex in the sense that in order to eff ectively have an impac t upon care, certain characteristics must be present in the CCDSS. Several systematic revie ws (Kawamoto, 2005; Roshanov, 2011) have found that improvement in care could be achieved t hrough implementation of a CCDSS. None of the trials specifi cally addressed pain care or p ediatric pain care in particular, so the applicability and impact cannot be commented upon directly. Th ese have also yet to demonstrate an impact on patient outcomes. Sleep evaluation Psychologist Table 62.5 Quotes of parents \200\231 perceptions of care at a MPC Perceptions of the MPC treating the whole body \200\230Knowing that they are looking at the whole picture, not just 1/4 of it \200\231 \200\230Th e mind \200\223body connection \200\224having both doctors meet with us togethe r was very helpful \200\231 \200\230Explaining how it \200\231s all going to come together to help our son. \200\231 Perceptions of the MPC team \200\230Th e process and desire to understand to assist and educate \200\231 \200\230How well the sta \200 worked to make me and my child comfortable and how to assis t my child when he has pain \200\231 \200\230People dedicated to getting the problem resolved. \200\231 Patient \202 ow for chronic pain services Figure 62.3 illustrates the stages of the patie nt fl ow through a MPC. Th e process begins with a referral, either by the patient \200\231 s general practitioner, another health care provided or health center. Clinic intake may be defi ned by diagnosis, duration of the problem or presence of psychological or social como rbidities. Text extracts reproduced from Jennifer Verrill Schurman and Craig A Friesen, Integrative tr eatment approaches: family satisfaction with a multidisciplinary pediatric: Abdominal Pain Clinic, International Journal of Integrated Care , Volume 10, p 1 \200\2239, Copyright 2 010 (CC By 3.0). results in frustration. However, aft er the coordinated interdiscipli- nary assessment, and once treatment plans are developed, parents are oft en quite appreciative of the service p rovided in the MPC team, especially with holistic and multidisciplinary team approach (Tabl e 62.5 ) (Schurman and Friesen, 2010). Many pediatric pain facilities are structured to off er a variety of health care services on the same day as the fi rst visits. Th is is not on ly convenient for fami- lies but establishes early on that a comprehensive examination of t he child \200\231s needs is being completed. Initial evaluation Organization of the data gathering process is important. Cott has argued that the initial interview for a complex problem requires the simultanous presence of the most senior clinicians; in other programs initial data gathering may use standardized ques- tionnaires administered by relatively junior clinicians or non-spe- cialists (Cott, 1987). Th e child should obviously be involved in all decisions (Desparmet, 2009). Th e evaluatio n of the patient should involve family members and consider the entire history and fam- ily dynamic. Parents should be prepared for the possibility of an extended meeting. A checklis t of items that should be discussed during this initial evaluation is provided in Table 62. 6 (adapted from National Health and Medical Research Council, 2005). Th e length of this ex tended fi rst contact interview can be anywhere from an hour to the better part of a day (W eisman, 2008). Parents and siblings should be incorporated into the interview, which will i nclude social history, school performance and extracurricular activities changes. Results are not always positive, however, and it is important to recognize when MPCs do not get it right so that these situations can be planned against. If expectations are not met, mistrust and sensitivity to future advice can arise: this represents a continuation of exp erience of failure derived from previous visits to other single modality specialists (Weism an, 2008). Negative experiences with MPCs include the length of a visit (including time wai ted between meetings) waitlist times, scheduling confl icts, and complexity of the interpre tation of outcomes. Parents expect the MPC to off er coping solutions and stress management skills (Claar and S charff , 2007). Th ey also anticipate SECTION 9 special topics 650 Referral From General Practitioner, Family, Hospital inpatient or emergency service Question Is there a clear diagnosis which accounts for the pain complaint and is that diagn osis currently being optimally treated? Make Appointment with one provider or a modality clinic based on location /type of pain Yes N0 Schedule patient with at least three providers including: Psychologist, Physician (pain specialist), and a select specialist depending on diagnosis. Plus a child life counselor or nurse (depending on child age and sta \200 availability) Provider suggests MPC treatment First Meeting Questions Is further investigation required? Is there evidence of physiologic al process which would cause \200\230harm \200\231 if patient began to participate in an a ctive recovery program? Patient tested/ assessed: Counseling is recommended: Treatment Prot ocol established: Pharmacist is incorporated if needed Initiate recovery program while investigation process (if needed) continues N0 De \201ne limits of recovery program to be pursued Follow up visits with appropriate providers Child life specialist, pharmacist Reassessment Reevaluate treatment plan, diagnosis Question: Is pain relieved or eliminated? Pain relief may not be an achievable goal althoug h understanding and management of the problem may be No Yes Maintain the treatment for ___ weeks (determined in assessment) Consult with team about pha sing the patient out of treatment Treatment has been successful? (No Relapse) Yes Discharge from the clinic. Figure 62.3 Patient \202 ow for chronic care services. Table 62.6 Patient assessment checklist (conducted with child and family present) Pain history information of signi \201 cance for symptomatic treatment of pain Expectations of outcome Circumstances associated with pain onset Patient belief around cause(s) of pain Primary site of pain Family belief around cause(s) of pain Radiation of pain Expected reduction in pain and symptoms required to resume regular activities Character of pain (throbbing, sharp, aching etc.) Patient \200\231s typical coping response for stress or pain, Intensity of pain during movement, at rest, and at present, during last week Presence of anxiety or psychiatric disorders (e.g. depression or psychosis) Highest level of intensity Family expectations and beliefs about pain, stress and postoperative course Factors altering pain (what makes it worse/better?) Ways the patient describes or shows pain Associated symptoms Source: data from National Health and Medical Research Council, Acute pain management: scie nti \201 c evidence , Sydney, Australia, Copyright 2005 Commonwealth of Australia. Temporal factors (is pain present continuously or otherwise?) E \200 ect of pain on activities E \200 ect of pain on sleep Physical exam, diagnosis, and feedback Th e physical exam including neurological exam (Desp armet, 2009; Weisman, 2008) and the diagnosis and feedback all provide both diagnostic and communication opportunities. Ensure adequate time for understanding, and confi rm comprehen sion (Desparmet, Medications taken for pain Additional treatments used for pain Health professionals consulted for pain treatment CHAPTER 62 organizational systems in pediatric pain 651 References American Society of Anesthesiologists. (2010). Practice guidelines for chronic 2009). Th is is where trust between provider and patient can be rein- forced. All questions should be answered thoroughly. Th e plan will be multifaceted and complex, and determined by pain management. Anesthesiology , 112 (4), 1 \200\22324 . the team during evaluation of the patient \200\231s needs and capabilities. American Society of Anesthesiologists. (2012). Practice guidelines for acute pain managemen t in the perioperative setting: an updated report by the American Society of Anesthesiologi sts Task Force on Acute Pain Management. Anesthesiology , 116 (2), 248 \200\223273 . Outcome goals are established in the feedback session, such as reintegration into various a spects of daily routine (Weisman, 2008). Families may not always accept the diagnosis and p lan, follow up should be encouraged. If the family is unwilling to return then the importan ce of a discussion with their family doctor should be emphasized. Refer to the section on p arents \200\231 perceptions about how to increase their satisfaction which has a highly pos itive association with adherence and good outcomes. Berde, C. and Solodiuk, J. (2003). Multidisciplinary programs for management of acute and c hronic pain in children. In N. Schechter, C. Berde, and M. Yaster (eds), Pain in infants, c hildren and adolescents (2nd edn), pp. 471 \200\223488 . New York : Lippincott Williams & W ilkins . Bonica, J. (1974). Organization and function of a pain clinic. In J. Bonica (ed.) Advances in neurology: international symposium on pain , pp. 433 \200\223443 . New York : Raven .