Understanding the context of practice Th e context of healthcare has been conceptualized in diff erent ways, ranging from the physical environment, as the most basic concep- tualizat ion, to more complex defi nitions such as that proposed by French: \200\230the organizatio nal environment of health care, composed of physical, social, political, and economic infl uences on the practi- cal reasoning and choices of practitioners about how clinical issues are address \200\231 (2005, p. 174). Promoting and sustaining behavior change Th e tendency for health professionals to adhere t o tradition and rituals and to become automated in their practice (Kerfoot, 1999; Monforto et al., 2012) means that unlearning previously well-entrenched behav- iour is necessary in order for them to adopt new evidence and modify their clinical practice accordingly. Docume nting PIPP scores 75% of the time in patient charts is an example of a notable improvement in clinical practice. However, sustaining this practice improvement remains a challenge and should be a focus of future research Over the past 20 years, studies conducted in several countries to examine the barriers to u se of research in practice have consistently highlighted the importance of time to implemen t change, time to read research, the nurse \200\231s authority to change practice, reportin g of understandable statistical analyzes in the research literature, and accessibility of r elevant literature, as the most prominent barriers to KT (Carlson and Plonczynski, 2008; Hu tchinson and Johnston, 2006; Kajermo et al., 2010). KT initiatives should, therefore, take into consideration the potential for such barriers to impede uptake of pain evidence within the specifi c practice context and incorpo- rate strategies to minimize or overcome them. Creating opportunities for interactive sharing of new knowledge, peer review, and dialog an d debate about how evidence could be incorporated into practice, are strategies that can be used to promote and sustain behavior change in order to facilitate KT. Additionally, promo ting positive attitudes and approaches towards pain assessment practices, engaging health p rofessionals in refl ec- tive practice, leadership that includes ongoing support, education , commitment to the practice change and performance evaluation can support and help sustain integration of evidence into practice (Davies et al., 2010). While much of the early work in the fi eld of KT focused on char- acteristics of the indivi dual and the research itself, it has become increasingly evident that the context in which knowledge is used is another important ingredient in the KT equation. In particular, eviden ce that research is adopted at diff erent rates and with diff er- ent levels of success in diff erent contexts has highlighted the impor- tance of context. In light of empirical evid ence to indicate that context can infl uence the success of KT (Cummings et al., 2007, 2010 ), it is essential that a careful assessment is undertaken of the pediatric healthcare cont ext in which pain evidence is to be imple- mented. Strengths and weaknesses in contextual c haracteristics can then be taken into account; capitalizing on the strengths and imple- men ting strategies to overcome or reverse the weaknesses. As well as identifi cation of potent ial barriers or challenges, an assessment of the receptiveness or readiness of the context to change is impor- tant. Meetings with key stakeholders (including health profession- als, administrators, educators and children and families) may be helpful in revealing issues an d concerns that should be taken into consideration. In summary, a theory-based approach to KT research can be used to guide and plan the study design, data collection methods, and analysis. Additionally, theoretical concepts can be us ed to explain study results and strengthen the construct validity of the specifi c theory, conceptual frameworks, and models used. Further, evi- dence-based KT strategies (i.e. educa tional strategies, reminders, audit and feedback) can be used to promote pain practice chan ges. References Azjen, I. (1991). Th e theory of planned behavior. Organ Behav Hum Decis Process , 50 , 179 \200\223211 . Azjen, I. and Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliff s, NJ : Prentice-Hall . American Academy of Pediatrics. (2000). Prevention and management of pain and stress in the neonate. Pediatrics , 105 , 454 \200\223461 . Anand K.J., Aranda J. V., Berde C. B., Buckman, S., Capparelli, E. V., Carlo, W., et al . ( 2006). Summary proceedings from the neonatal pain-control group , Pediatrics , 117 , S9 \200\223S22 . anonymous. (2000). Prevention and management of pain and stress in the neonate. American Ac ademy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthe siology. Section on Surgery. Canadian Pediatric Society. Fetus and Newborn Committee. [Guid eline Practice Guideline]. Pediatrics , 105 (2), 454 \200\223461 . Several measures have been developed for health professionals and researchers to evaluate t he practice context. Kitson et al. (2008) developed a practical diagnostic assessment tool (which comple- ments the PARiHS framework) to inform development of an imple- mentation str ategy. Th e tool is designed, to help identify aspects of the current environment or contex t that need to be addressed in order to optimize KT. An aggregated score can be plotted on an evaluative grid to enable visualization of the level of facilitation support required to optimize implementation. Th e Alberta Context Tool (ACT) (Estabrooks et al., 2009), based on elements from the Bandstra, N. (2007). Knowledge translation in psychological interventions for pediatric pai n: bridging the gap between research and practice . In C. L. von Baeyer (ed.) Pediatric pai n letter , 9 (3). Available at: <http:// childpain.org/ppl/issues/v9n3_2007/v9n3_bandstra.p df>. Batton, D. G., Barrington, K. J., and Wallman, C. (2006). Prevention and management of pain in the neonate: an update. Pediatrics , 118 , 2231 \200\2232241 . SECTION 9 special topics 640 Bero, L. A., Grilli, R., Grimshaw, J. M., Harvey, E., Oxman, A. D., Th omson, M. A. (1998). Getting research fi ndings into practice: closing the gap between research and practice: a n overview of systematic reviews of interventions to promote the implementation of research fi ndings. 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CHAPTER 62 Organizational systems in pediatric pain Mark Embrett and Norman Buckley Introduction Over the past 20 years there has been growing recognition that pediatric pain management can be delivered in a variety of forms, and may be best delivered in a multidisc iplinary set- ting with a shared responsibility amongst diverse health provid- ers, who tra ditionally have worked independently from each other or at best in parallel. (Desparmet, 20 09; Dowden et al., 2008; Weisman, 2008). Th e composition, size, and organization of a pedi atric pain management team can diff er based on the number and type of patients served, as well as the organizational structure of the health care center (hospital, clinic, community health center, etc.). Th ere is no one \200\230right \200\231 way to organize the team, b ut diligence is needed when planning a multidisciplinary delivery method. Th is chapter pre sents some of the considera- tions relevant to organizations that are designing a new team, modifying a current arrangement, or assessing the performance/ needs of an existing team. Acute pain, chronic pain, and palliative care: common elements of treatment and potential s hared resources All pain in children has the potential to disturb developmental proc- esses . Th is section reviews the similarities and diff erences between experiences of and treatm ent options for acute pain, chronic pain, and palliative care. Acute pain is the result of an identifi able injury, an acute illness, or surgery. Many of the tenets of the multidisci - plinary model of chronic pain care also apply to acute pain serv- ices; however, the usua l course of acute postoperative or postinjury pain is time limited and may resolve with les s overt management of the behavioral aspects. Growing awareness of the presence of \200 \230persistent postsurgical pain \200\231 in acute care settings does suggest that there sh ould be clearly defi ned mechanisms in pediatric care for appropriate treatment if pain per sists beyond the expected injury resolution. Chronic pain through its persistence has the p otential to greatly disrupt social and psychological processes, as the child and their fami ly respond to the pain and their understanding (or lack thereof) of the factors contributin g to it. It may be associated with persisting physiological disturbance (e.g. neuropathic p ain from diabetic neuropathy or chemotherapy), or it may be a manifesta- tion of behavioral changes arising out of a physiological event now otherwise resolved, or it may represent a behavioral manifestation of distress because of the source of the initial pain (i.e. cance r now resolved?) or a psychological/psychiatric disorder. Pain associated with terminal ill ness adds additional suff ering to a situation already fraught with distress. Whatever the individual situation, the biopsy- chosocial model of pain presents a very useful theoretica l frame- work in which to consider the organizational structure necessary to provide treatm ent. Each factor will be operating to a greater or lesser degree in each situation where pa in is manifest, and must be considered in the treatment approach. Organizational systems should facilitate the care to be deliv- ered. Th e process of patien t referral and triage should be expedi- tious, the initial assessment process must identify the issues to be dealed with and ensure that optimal management has been car- ried out for medical, surgical, psychiatric, and other identifi able disorders. Th e business of the se rvice or clinic (revenue sources, salary support, supplies, and materials) must be consider ed. Th e resources (personnel, supplies, programs) necessary for the care plan must be read ily available, organized, and care delivered in an eff ective manner with monitoring of the eff ect and revision as necessary. Th e chapter fi rst focuses on an overview of the similar ele- ments to approaches of chron ic pain, acute pain, and palliative care, concluding with a description of the ideal multid isciplinary pain management approach (MPMA). Th e chapter then proceeds to review the speci fi c organization and operations of acute pain and chronic pain services, respectively. Fin ally, research about the expectation of parents when they enter a clinic and impor- tance o f accommodating and promoting positive expectations is presented. Th e patient fl ow proces s in acute pain diff ers from the chronic pain model and is described. Th e emphasis remain s on consistent clear communication among providers and between providers and patient/famil y. Th ere are both common and unique elements of care for acute pain management, palliative ca re, and chronic pain management. For the acute pain situation, in the case of scheduled sur gery, preparation will be helpful (child life); treatment will be directed by acute care me di- cal providers \200\224either surgeons or a \200\230pain service \200\231 usually consi sting of anaesthesiology and nursing, oft en advised by a pharmacist, interact- ing with th e surgical and nursing care teams. Illness and injury will CHAPTER 62 organizational systems in pediatric pain 643 benefi t from the developmentally appropriate educational services of child life, well-trai ned nurses and in some cases technical interven- tions from anesthesia. Communication with the child and their fam- ily members is important to ensure understanding of the illness or injury itself, and the meaning of pain in the process. Palliative care requires attention to the spiritual aspects of the impending death, as well as necessary and appropriate medic al care, analgesia as deter- mined by the process and impact of the pain. Th e family must also be cared for. When pain has become chronic, one important issue is to ensure that any responsible disease process has been defi nitively identifi ed and is under optimal medical therapy (Cott, 1987). Since function may have deteriorated signifi cantly during the \200 \230chronifi ca- tion process \200\231, return to normal function may not occur without a s tructured treatment/recovery plan. network of interested colleagues) will be essential to successful treatment. Our descriptio n of acute and chronic pain programs will, it is hoped, identify the necessary elements and suggest some organizational structures and processes which will support best practice care . MPMA refers to the practice of combining physiological, pharma- ceutical, psychological, an d sociological therapies at the same time to achieve improvements in outcome. Th ese servic es have histori- cally been provided in separate locations both within and outside the hosp ital setting. However since Dr John Bonica fi rst described multidisciplinary treatments be ing provided together in one set- ting (Bonica, 1974), the concept has seen considerable gr owth in the health care arena (Howard, 2003; Reid et al., 2010; Roy, 2008; Weisman, 2008). Th e type of services off ered in a pediatric pain facility depends on the expertise and fo cus of the practicing profes- sionals (McCLain, 2000; Weisman, 2008) but the goal should be to achieve a service equivalent to the Multidisciplinary Pain Clinic as defi ned by the In ternational Association for the Study of Pain (IASP); teaching institutions will target the Pain Center (International Association for the Study of Pain, 2012) (Table 62.1 ). Any acute care pediatric treatment facility will require all of these elements \200\224prep aration, acute pain control services, counsel- ling and spiritual support, multidisciplinar y care \200\224at least some of the time. Surgery requires preoperative preparation and pos topera- tive analgesia. Palliative care requiring counseling, supportive care, and a wide p otential range of symptom management is an unavoid- able need for any facility treating ser ious illness and cancer. Even in the absence of a formal chronic pain program, there will s till be situations where children present with persistent pain and behav- ioural changes. E xpertise in the form of at least some specialists with the appropriate training and a netwo rk (even if it is a virtual It has become standard for acute and chronic pain management in children to be performed in a multidisciplinary setting (Peng et al., 2007). Pain centers are the largest and most com plex facili- ties and viewed as the ideal (Weisman, 2008). Th ey also require signifi cant resources. Quite oft en they focus on outpatient services Table 62.1 Preferred characteristics of multidisciplinary pain clinics/centers Quali \201 cations A variety of health care providers trained to assess and treat physical , psychosocial, medical, vocational, and social aspects of chronic pain It is required to b e able to assess and treat both the physical and the psychosocial aspects of children \200 \231s complaints. Th erefore, at least three medical specialties should be represented, one of which should be a psychiatrist or clinical psychologist (see below for other specialtie s) Be able to deal with a wide variety of chronic pain patients, including those with pain due to cancer and pain due to other diseases Have a consistently adequate number and variet y of patients for its professional sta \200 to maintain their skills in diagnosis and trea tment All Health care providers should be appropriately licensed and have signi \201 cant knowledge of both the basic sciences and clinical practices relevant to chronic pain patien ts 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 .