Children’s pain management: A new standard to improve care

In this podcast, Dr. Katie Birnie discusses pediatric pain management, focusing on the newly developed National Pediatric Pain Management Standard, the first of its kind in the world. A collaboration between Solutions for Kids in Pain (SKIP) and the Health Standards Organization, the new standard establishes a set of guidelines for the delivery of pain management for children from birth to 19 years. It provides guidance to healthcare organizations on how to deliver equitable and quality pain management across hospital settings serving children and youth. This standard sets the stage for improving pain management in children and youth across the continuum of care.

Overall, this podcast highlights the ground-breaking work being done in Canada to improve the management of pain in children and youth, with a strong emphasis on equity, patient partnership, collaboration, and implementation.

Transcript

Transcript: Children’s pain management: A new standard to improve care

Connected by purpose. Driven by passion. This is Children's Healthcare Canada’s SPARK: Conversations podcast series. 

Katharine: Welcome to SPARK: Conversations, Children's Healthcare Canada’s monthly solutions-focused podcast that connects the child and youth health community with systems leaders who tackle wicked problems and discuss ideas to inform the development of innovative and integrated systems serving children and youth. 

 I'm Dr. Katharine Smart and today, in honour of Pain Awareness Month, I'm delighted to be speaking with Dr. Katie Birnie, about Pediatric Pain Management. Dr. Birnie is a Clinical Psychologist and Assistant Professor in the Department of Anesthesiology, Perioperative, and Pain Medicine at the University of Calgary where she leads the Partnering for Pain patient-oriented research program. She is the Associate Scientific Director of Solutions for Kids in Pain (also known as SKIP), a national knowledge mobilization network working to improve children’s pain through coordination and collaboration. Dr. Birnie also provides clinical care to youth living with pain and their families at the Alberta Children’s Hospital. Dr. Birnie chaired the national working group that developed the world’s first National Health Standard for Pediatric Pain Management with SKIP and the Health Standards Organization published April of 2023.

Hello Katie and welcome to SPARK: Conversations.

Katie: Hi, Katharine. It's a pleasure to be here.
 
 Katharine: I'm really looking forward to our conversation today. Such an important topic. So Katie, I'm going to dive right in, you obviously recently led the development of the National Pediatric Pain Management Standard, the first of its kind in the world. So a big deal. Once again, we see Canada playing a leader in pain management for children. So can you tell us a bit about the National Pediatric Pain Management Standard and how it was created?

Katie: Absolutely. So you're right to say it's the first of its kind in Canada and the first of its kind in the world, which is a phenomenal opportunity where we've been able to lead in an area both in child health. So there is no pain standard even for adults in Canada or internationally. So truly, truly, we're leading the way with child health at the at the forefront. So this, as you said, in your introduction, this came about through a partnership between SKIP and the Health Standards Organization. And the Health Standards Organization is a national organization that really works in the development of health standards, or to create standards of Canada in particular areas in health. So we set out to do this, we had a working group of about 15 different folks with diverse expertise in this area and included people with lived experience. So their own lived experience of pain during childhood or as caregivers or family partners, diverse health professionals from across the country, including physicians, psychologists, physical therapists, child life specialists, nursing, as well as hospital administrators, so people in managerial roles within hospitals, and experts in the development of health standards. And it really lays out a criteria for how hospitals that serve children from birth up to 19 years of age in any hospital in Canada. So those children's hospitals, but also community hospitals. It lays out guidance on how to deliver quality equitable pain management, in all areas of the hospital. So medical procedures, surgeries in the emergency departments, but also in the context of chronic pain or pain that lasts months to years.

Katharine: Wow, that's fantastic. And so important. You know, I find in my own practice, this is such an area where people can really struggle. So it's incredible to have those guidelines to sort of lead the way in terms of best practice.

Katie: Yeah, absolutely. And I will say, you know, Canada is a world leader in producing pain research, so the knowledge about how to best effectively manage children's pain. But we're very behind in actually applying that knowledge and expertise into practice. And I think it's really reasonable that families across Canada can expect that their kids when they go into hospital are getting the best possible care with the knowledge that we have now. And this standard just really helps us to bridge that gap more effectively and efficiently.

Katharine: That's fantastic. And leads really into my next question, which is, you know, knowing that this national standard was released in April 2023. And as you've already stated, it's so important to get that information out there. What have you and SKIP and the Health Standards Organization been doing since the launch to socialize, promote and implement this standard across the country?

 Katie: Yeah, so the standard itself was released on April 3 2023. And I'll just put a shout out there that it's actually available for free so anybody can download it from the Health Standards Organization website, in English or in French, and it was launched on April 3, and we had an incredible launch period of time. So we were, we were just timely, I think it speaks to the relevance of child health, actually pain as a priority area in Canada at the moment, and got incredible media uptake around the standard across, you know, television, print, and radio. Up to 131 million views, you know, in terms of..so if you live in Canada, you basically heard about it. Which is pretty incredible. And since that time, I don't have the updated stats now. But as of June, we, the standard had been downloaded almost 900 times from about 54 different countries around the world. So there's clearly a lot of interests both within Canada itself, but just also nationally in what we're doing.

And I bring all of that up just to say, you know, building awareness of that the issue of children's pain management, and the existence and importance of a standards like this, is really a first step towards its implementation and ensuring that it has impact. So certainly, we got off to the right start out of the gates and really had some incredible success at that point. And really, we've also been engaging in a whole variety of other activities. The primary audience for the standard, as is true for any health standard, really are those organizational leaders within hospitals, in this case, as well as health professionals. But of course, also family members who are really important advocates and partners, which this standard also highlights; key partners in any child's care, including their pain management. So we've been meeting with a variety of hospital leaders across the country and senior management, to really share about the standard and begin to have conversations about how it can be implemented as a priority area within their hospitals. We've also been presenting and sharing with a variety of health professional organizations, whether that's physicians or nurses or child life specialists and so on. And also sharing it publicly, you know, including also in mixed audiences where there will also be children and youth and families.

We're also working increasingly with implementation experts to really say, you know, as SKIP with our six hubs across the country, very well embedded with incredible expertise within our organization, but how to mobilize knowledge about children's pain into practice and policy, as well, you know, and really drawing on that to work closely with hospitals. We're also engaging with policymakers. So here in Canada, we have a Pain Policy Group within Health Canada, which really came out of a National Canadian Pain Taskforce that published an action plan for pain in Canada in 2021. And things like this National Health Standard were really identified as priorities to really tackle this huge problem of poorly managed pain that we have in Canada across the lifespan. So we've been sharing with policymakers within government, who have a keen interest in this both as priority areas for child health, but also just priority areas for families, whether it relates to pain and mental health, or substance use. And having conversations to make sure pain is on and as part of those priority conversations around mental health and substance use, which we know tend to co-occur, particularly with chronic pain. And we should really be having all of these conversations together as standards are being developed in those areas across the country as well.

So we've been doing a lot already, but we certainly know we're not done yet. And we're continuing, like I said, to engage in those conversations and are excited to be putting into place more opportunities to draw folks in with resources and support and expertise to ensure they can implement aspects of the standard or the whole standard as quickly and effectively as possible.

Katharine: That's fantastic. You guys have taken such a comprehensive approach. But you know, what I'm wondering is how you're finding time for your clinical practice amongst all this work you've been doing because it really sounds like the scale of it is clearly massive. So it's incredible. So congratulations, and thank you for your leadership in this space.

Katie: Thanks Katharine. I'm certainly not doing it alone, right. I think you know, with something like this, I mean, it's why an organization like SKIP is valuable. SKIP has a close partnership with Children's Healthcare Canada, and Children's Healthcare Canada has been a co-leading organization with SKIP over the past five years now. And you know, opportunities, connections, diverse experts, really creating space for folks to own and be engaged and many are. People are excited to make sure that they're delivering the best care for children and families and poorly managed pain is not something that's only hard for children and their families but it's also hard for health professionals as well. And to know that you're doing everything you can and ensuring a great care experience is something I think we all want to be part of.

Katharine: Yeah, I absolutely agree. And I've often thought about that, in my own work as a pediatrician, it's those moments where you're having to do painful procedures or suggest something for a child that you know will be uncomfortable; that are often sort of the worst parts of the work, right, because no one enjoys making someone not feel good. So I think, you know, as we improve our ability to do those necessary things, but in the best way possible, it really does change the experience for everyone.

So I think that really leads us to the next question, which is, you know, this is an incredible initiative, it's obviously very comprehensive. I would love to hear from you, what impact you feel the standard can have on healthcare for children and youth. What it means for Canada's children and the health professionals who work with and for them, and what difference you're seeing it making already?

Katie: Yes, that's a big question. And, you know, we hope for great things of course, when you put out something like a health standard. I mean, I think the things some of the things I've been reflecting on and learning and talking about through conversations with others, some are certainly specific to the area of children's pain management, but some are much broader and much go well beyond pain management specifically. I think there are key things within this health standard that really talk about patient-partnered care. And this idea of really ensuring that children and youth and family members are considered equal members of their health care team, that their expertise is valued, and it's listened to. You know specifically in this area, we also talk about children who cannot communicate verbally, but how pain is so subjective, and we really need to be relying and building up the communication, ability and flexibility of the children's themselves, but also their families in that process. But I think that's something that that really, you know, should apply across all areas of child health and healthcare in general.

The other piece we really took on in this was ensuring a strong equity-oriented approach as part of quality pain care. So really trying to move forward these ideas that equitable pain management include, you know, pain care that is anti-oppressive, anti-racist, anti-ablest, culturally informed, individually tailored and trauma and violence informed. And so, you know, we really engaged in addition to our National Working Group, an additional five experts, whether it was areas related to black children, black youth, youth of color, indigenous youth and families, to ensure that what we were putting forward and the criteria and the standard and the guidelines around it, really tried to tackle that equity piece. And there are many areas of children's pain that have, you know, been inequitable, and unfortunately, continue to be so. But I think we also see that in some of the existing health systems and practices that continue. So I hope this also, you know, on behalf of our working group, I think we all also hoped to see this as a leap forward kind of in that conversation.

And I think just standards in general, give us an opportunity that, you know, other clinical practice guidelines or other guideline documents around best practice, don't necessarily have. So a standard is so comprehensive. We're tackling what needs to happen both at the individual health professional patient and family interaction, in terms of the types of treatments that have some evidence behind them. But we're also tackling how does the health system need to change or need to adapt to ensure that health professionals are supported and able to actually carry out that practice in those individual encounters. So whether that's quality improvement, what supports organizational leaders need to put into place, you know, things that need to connect within the health record, or resources that need to be available and accessible to health professionals and families. So those are some of the things that you know, I think about that, that certainly have applicability, more broadly, and I think are really exciting about this health standard in particular.

Katharine: Oh, absolutely. And I think like you say, you know, drawing it to those broader systems issues, and really some of these challenges that really over arch care delivery across the spectrum of care that we tried to deliver and how you've been able to bring sort of awareness through something like pain, which really, you know, does permeate a lot of different aspects of care and is experienced in a lot of different ways. So I think it's really interesting how you can take what you know, might be perceived as simply a clinical issue, but really relate it to the health system and these broader equity issues as well. So I think those links are probably really helpful. And help all of us think a little bit about, you know, the systems we work in how they're designed and what that means for the care that we provide patients.

Katie: Yeah, absolutely.

Katharine: So at this point, what do you think needs to happen for more children's hospitals and community hospitals serving children and youth to be able to implement this standard?

Katie: Yeah, that's the million-dollar question, isn't it Katharine? Some of the things we've been chatting a lot about. I mean, I think, you know, of course, we want to see everybody adopt the entirety of the health standard. You know, we do, of course, think everything in there matters. But I think, you know, for me, and for many folks, I've been chatting with it, it's really also making sure that pain isn't a separate issue. Pain, and the proper management of pain really touches all area, all areas of children's health. Whether it's medical procedures, you know, whether it's, you know, show pain is a primary reason why primary symptom people are showing up within the emergency department. About 20% of youth who undergo major surgery will develop chronic pain, and about 20% of youth will deal with pain that lasts months to years or chronic pain before they reach adulthood. And so it is a really common prevalent issue. But we have great solutions to do so. So I think what we also hope to see in the standard is where folks can see where pain is part of other conversations and priorities that are already at play in child health. So I mentioned mental health and substance use already. Those are key areas where pain either puts people at risk, and or is a consequence of some of those challenges.

But another key piece in the standard where we're getting a lot of traction in conversation is a criteria. So there's 34 criteria in the standard, but one of the criteria outlines poorly managed or preventable pain as a patient safety incident. And we know patient safety is such a key priority issue for child health, but also for the health system in general. And so pain just needs to be part of that conversation, too. As we're coming up with other systems and solutions and organization-wide solutions, about how to identify and review and address other patient safety concerns. Let's make sure that pain is on that list. So I think those are our ways that, you know, I think we can continue to make strides and really bring this piece into the broader conversation.

Katharine: Yeah, absolutely. And, you know, I think you outlined so clearly, it's such a common experience for people seeking care, that really everyone needs to be thinking about it, integrating it into their practice approach. And I think all of us need to be learning more about what to do and how to provide that care at that, you know, at a level that meets the knowledge that we now have. And it's such a great example, I think of an area that's really developed. You know, when I think 20 years ago, when I started in pediatrics, we didn't talk about this a whole lot. Right. You know, we certainly talked I think about somewhat about acute pain, but situating pain the way you've been describing it, I don't think we were necessarily having those conversations. So it's, it's great to see something so important, really evolving into this much more holistic approach, to make sure that we're all developing those skills, and really making sure the care that we give is sensitive to the people we're trying to serve. So, again, thank you for your leadership in this space. I think it's really, really key.

And I'm curious, in that vein, how you feel, you know, you mentioned the partnership with Children's Healthcare Canada, what can organizations like Children’s Healthcare Canada and others do to support their members and partners in the implementation effort of something that's so critical for kids and youth?

Katie: Yeah, I think, you know, top of mind, the health standard is available for health care organizations and health care leaders to access. It's not a required part of accreditation, but it's available so that organizations can elect to be assessed against it on a voluntary basis. So just to a shout out to those organizational leaders who might be listening, this is a chance to elect to do that and ensure that your institution is really a leader in putting into practice what we already know works. Right and many simple solutions around children's pain. You mentioned Children's Healthcare Canada in particular and you know, thrilled to be speaking today as part of this podcast series. And Children's Healthcare Canada actually launched late in the spring, a Pain Practice and Policy Network in partnership with SKIP. Getting off the ground, meeting monthly, really pulling together pain champions from institutions across the country, who really want to continue to ensure and to tackle some of the issues around implementation of the health standard. And I know in partnership with SKIP will only continue to see that to grow. Oh sorry, will continue to see that grow over time as we continue to seek opportunities to further resource and support the implementation aspect of the health standard, which we actively do together.

I think we've also seen opportunities to present and engage organizations like the Canadian Pediatric Society. I had the privilege of co-presenting about the health standard at their spring meeting. And I think really seeing you know, as they put out position and practice statements, and other leading organizations like CPS do, really tying to and seeing that alignment and really ensuring that that their guidelines, recommendations and so forth, are really are consistent with what's been put out within the health standard as well.

There's also a section in the health standard about, you mentioned, you know, not being as knowledgeable in the past about some of these things. And there is a whole section about professional development to create a knowledgeable and confident workforce. It's one of six sections in the standard itself. And so you know, where we also think about how we support training all the way along, right for health professionals and administrators, as far back into their university training. But also patients and families and folks who come in and work at all of these hospitals to make sure that they're well versed and able to engage with it. So just some examples, I think, no shortage of things we can continue to build on.

Katharine: Oh, it's fantastic. And I just love how broad and again, and how comprehensive your approach is. So Katie, this sounds like a massive project that you've been part of. And I appreciate, there's been lots of partners, but it's clearly been a huge body of work. So what's next for you?

Katie: Oh, gosh, what a great question. You know, I'm really excited to continue to support moving the implementation of the health standard forward, you know, I'm trained as a clinical psychologist, I'm also a researcher, I've had the privilege to work clinically at three different children's hospitals in the country and two adult hospitals, over the course of my training and career so far. So I see the need, I care about this as a topic. And you know, it was truly an honor to be part of, as you mentioned, a group of folks to create something so big and so impactful. Which we you know, you hope it has that impact it was three years in the making, and to see the engagement and interest and response to folks about it has been very humbling and just really exciting. So I look forward to continuing to support this in a variety of different ways, with all of those hats that I wear. Whether it's, you know, as a health systems leader, as a clinical psychologist, myself or as a researcher. And just continuing really to bring other people in, because these are the types of big change that you definitely can't do alone. And how do we make sure that that health professional who's working on that unit or in that emergency department or you know, in that outpatient clinic to really also feel supported and engaged and excited and able to make change within their own practice in their own institution as well.

Katharine: Well, thank you, Katie, it sounds to me like you've already had a huge impact and are really setting well, as you said, the standard for what we should all be doing across the country; and your leadership and your teamwork in this space is so fantastic. So I really want to thank you for sharing your insights and experience with us today. And also just for our listeners directing them towards this resource, which sounds to me could be implemented really at any level of care. So it's great for our listeners to know about that, and if they haven't been one of the people to see it yet to seek that out. So I want to thank you for speaking with us today and in sharing all your knowledge and experience.

Katie: Thanks so much, Katharine. And folks, if they're not sure where to link to it, they can also check out the Kids In Pain website, kidsinpain.ca. We have a link on the homepage there to an executive summary about the health standard and then to the health standard itself through the Health Standards Organization. And there you can also find one pagers or brief pagers there are actually more than one page for health professionals and for youth and families about the health standard itself. And thanks again for the invitation and a real pleasure to speak with you.

Katharine: Thank you. So to all our listeners stay safe and be well. To stay up to date on all our SPARK offerings, including upcoming podcast episodes, visit our website at ChildrensHealthcareCanada.ca and subscribe to our SPARK: News bi-weekly e-bulletin if you haven’t already. Thanks for listening to SPARK: Conversations. And before we go show some love for your new podcast series by leaving us a review and then join us again next month. Thanks everyone.