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From the *Ann & Robert H. Lurie

Children’s Hospital of Chicago,

Chicago, Illinois; † Northwestern

University Feinberg School of

Medicine, Department of Pediatrics,

Chicago, Illinois.

Address correspondence to Suma Rao-

Gupta, MPH, MBA, Director, Pedersen

Family Learning Center and Health

Sciences Library, Clinical &

Organizational Development, Ann &

Robert H. Lurie Children’s Hospital of

Chicago, 225 E. Chicago Avenue, Box

47, Chicago, IL 60611-2991. E-mail:

[email protected]

Received July 7, 2017;

Revised October 13, 2017;

Accepted November 5, 2017.

1524-9042/$36.00

� 2017 by the American Society for Pain Management Nursing

https://doi.org/10.1016/

j.pmn.2017.11.002

Leveraging Interactive Patient Care Technology to Improve Pain Management Engagement

- - - Suma Rao-Gupta, MPH, MBA, *

David Kruger, MSN, RN, CNML,*

Lonna D. Leak, MS, BSN, RN, NE-BC,*

Lisa A. Tieman, BSN, RN, CPN,*

and Renee C. B. Manworren, PhD, APRN, BC, APN-PM,

FAAN *,†

- ABSTRACT: Background: Most children experience pain in hospitals; and their par-

ents report dissatisfaction with how well pain was managed. Engaging

patients and families in the development and evaluation of pain treat-

ment plans may improve perceptions of pain management and hospital

experiences. Objectives: The aim of this performance improvement

project was to engage patients and families to address hospitalized pe-

diatric patients’ pain using interactive patient care technology. The goal

was to stimulate conversations about pain management expectations

and perceptions of treatment plan effectiveness among patients, par-

ents, and health care teams. Methods: Plan-Do-Study-Act was used to

design, develop, test, and pilot new workflows to integrate the interac-

tive patient care technology system with the automated medication

dispensing system and document actions from both systems into the

electronic health record. Setting: The pediatric surgical unit and hema-

tology/oncology unit of a free-standing, university-affiliated, urban

children’s hospital were selected to pilot this performance improve-

ment project because of the high prevalence of pain from surgeries and

hematologic and oncologic diseases, treatments, and invasive proced-

ures. Results: Documentation of pain assessments, nonpharmacologic

interventions, and evaluation of treatment effectiveness increased. The

proportion of positive family satisfaction responses for pain manage-

ment significantly increased from fiscal year 2014 to fiscal year 2016

(p ¼ .006). Conclusion: By leveraging interactive patient care technolo- gies, patients and families were engaged to take an active role in pain

treatment plans and evaluation of treatment outcomes. Improved active

communication and partnership with patients and families can effec-

tively change organizational culture to be more sensitive to patients’

Pain Management Nursing, Vol 19, No 3 (June), 2018: pp 212-221

p ri n t &

w e b 4 C = F P O

213Interactive Patient Care Technology Improve Pain Management

pain and patients’ and families’ hospital experi-

ences.

� 2017 by the American Society for Pain Management Nursing

Parents play a vital role in children’s pain experiences

(Palermo, Valrie, & Karlson, 2014; Simons, Goubert,

Vervoort, & Borsook, 2016), and parents’ satisfaction

with children’s pain treatment is a key outcome measure for hospitals (McGrath et al., 2008). Because

more than 80% of hospitalized children experience

acute pain from their disease or injury, treatment,

and invasive procedures, including surgery

(Kozlowski et al., 2014; Solodiuk et al., 2014;

Walther-Larsen et al., 2017), it has been suggested

that parents’ involvement with management of pain

during children’s hospitalization will significantly reduce overall pain perception (Habich et al., 2012;

Simons, 2015). A focused effort is required for nurses

to engage and partner with parents to better identify,

acknowledge, and manage pain experiences of

hospitalized pediatric patients.

In fiscal year 2014, parents’ satisfaction with their

children’s pain treatment at Ann & Robert H. Lurie

Children’s Hospital of Chicago (Lurie Children’s) was not statistically different than those for other Chil-

dren’s Hospital Association (CHA) facilities. However,

FIGURE 1. - Proportion of positive responses to HCAHPS pain qu child’s pain?’’ Statistically significant difference p < .05. HCA viders and Systems; CHA ¼ Children’s Hospital Association FY15 ¼ fiscal year 2015; FY16 ¼ fiscal year 2016.

parents’ satisfaction was lower than desired (Fig. 1).

These survey results and an opportunity to leverage

technology to improve parents’ engagement in pain

treatment motivated the health care team to pursue

new methods to partner with parents to improve the

organization’s approach to pain management and hos-

pital experiences. The GetWellNetwork Pain Pathway was identified

as a potential conduit to strengthen effective collabora-

tion with parents to better manage hospitalized chil-

dren’s pain. Therefore, the aim of this performance

improvement project was to implement an engage-

ment initiative to address pain in hospitalized pediatric

patients using GetWellNetwork interactive patient care

technology (IPC). The goal was to stimulate conversa- tions about pain management expectations and per-

ceptions of the effectiveness of treatment plans

among patients, parents, and health care teams.

METHODS

The Plan-Do-Study-Act performance improvement

model was used to design, develop, test, and pilot

new pain assessment workflows. IPC uses the patient’s

bedside television to deliver interactive educational

and entertainment content. Content includes both,

clinical tools that allow bedside staff to order targeted health education and launch IPC pathways, and

estion: ‘‘Did staff do everything they could to manage your HPS ¼ Hospital Consumer Assessment of Healthcare Pro- benchmark; FY14 ¼ fiscal year 2014, baseline measure;

p ri n t &

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214 Rao-Gupta et al.

entertainment options, such as movies, internet, video

games, and streaming music options (Kompany, Luis,

Manganaro, Motacki, Mustacchio, & Provenzano,

2016).

Setting Two inpatient units, the Pediatric Surgical and Solid Or-

gan Transplant Unit (Pediatric Surgical Unit) and the Hematology/Oncology and Transplantation Unit (He-

matology/Oncology Unit), were identified as pilot

units for this performance improvement project. These

units were selected because of the high prevalence of

pain from surgeries and hematologic and oncologic dis-

eases, treatment, and invasive procedures. The Pediat-

ric Surgical Unit has 48 beds with an average daily

census of 33 patients. The Hematology/Oncology Unit has 24 beds with an average daily census of 20.5

patients. Staffing ratios for both units vary by patient

acuity but are budgeted for one registered nurse for

every three patients (1:3).

Project Team The core project team included representatives from

nursing, patient-family education, information technol-

ogy, nursing informatics, pharmacy, and our IPC vendor, GetWellNetwork. Members of each unit’s lead-

ership, including nurse educators and pain manage-

ment champions, were key members of the project

team. This multidisciplinary project team met weekly

to discuss workflows, logistics, and the information

technology build. Staff who had a passion for pain man-

agement, technology, and improving the patient and

FIGURE 2. - Workflow redesign illustrating AMD & EHR integrati dispensing system; EHR ¼ electronic health record; RN ¼ regi technology. Copyright �2017, GetWellNetwork Inc. Reproduce

family experience championed this effort and

informed colleagues about the new workflows.

Workflow and Pathway Development The project team decided methods to stimulate discus-

sion and better communicate the organization’s commit-

ment to partner with patients and families to address

pain were needed. Direct care nurses were identified

as the primary health care providers to engage families

in pain management. At Lurie Children’s, direct care nurses coordinate care and play an integral role in part-

nering with patients, families, and the multidisciplinary

health care team from admission to discharge.

Admission Pain Pathway. The project team identi- fied the time of admission as critical for initiating part-

nerships with patients and families, and direct care

nurses identified the need to make pain management

a priority for care on admission (Fig. 2). Two questions were added to the inpatient admission assessment tool

for the nurse to ask the parent/caregiver (Table 1).

Once the admission assessment is completed, pa-

tients and families are required to watch two videos to

access entertainment options. The first video focuses

on patient safety and orientation to the hospital stay.

The second video, ‘‘Partnering in Pain,’’ explains the

hospital’s commitment to pain management. This 90- second video was created by direct care nurses to

inform patients and families of the desire and goal to

partner to address pain. The video is available in En-

glish and Spanish. The video provides a mechanism

to assist direct care nurses to discuss with patients

and families pain management expectations, assess-

ment strategies, interventions, and preferences.

on with GetWellNetworkTM. AMD ¼ automated medication stered nurse; Rx ¼ prescription; HIT ¼ health information d with permission.

TABLE 1.

Added Admission Assessment Questions and Rationale for Added Questions

Question Rationale

Question 1: At Lurie Children’s we want to do all that we can to provide comfort and relieve pain for our patients. Have you discussed pain management with the patient or caregiver?

This question serves as a prompt for the nurse to start a conversation with the patient and parent and/or guardian. This question helps the caregiver establish a conversation regarding pain management at the time of admission.

Question 2: What things have helped you (patient) or your child’s (parent) pain management in the past?

This question helps the health care team incorporate methods identified to relieve and cope with pain into the patient’s care plan.

p ri n t & w e b 4 C = F P O

215Interactive Patient Care Technology Improve Pain Management

Ongoing Bedside Communication. Each patient room has a whiteboard with one area specifically de-

signed to document the patient’s pain plan (Fig. 3). Pa- tient and parent responses to admission assessment

questions are transferred onto the whiteboard. This in-

formation is then readily available to all health care

team members, as well as the patient and family. The

goal of the whiteboard is to facilitate communication

of the pain plan and to serve as a reminder to the pa-

tient, family, and members of the health care team

regarding how to intervene to manage the patient’s

FIGURE 3. - Photos of whiteboards in patient rooms. Patient- section.

pain or what has been done to address the patient’s

pain. It facilitates continued communication regarding

how to address pain and pain control at the bedside.

Daily Leadership Rounds. The leadership of the pi- lot units defined their role as promoting conversations

with patients, families and health care teams related to

pain and the effectiveness of pain management plans. They identified the need to endorse daily communica-

tion about pain to foster an organizational culture sen-

sitive to patients’ pain and hospital experiences. The

pilot units’ leadership teams began including questions

specific information is documented under the Pain Plan

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FIGURE 4. - Modification of the Revised Faces Pain Scale, as seen on screen. This prompt was triggered to display on Get- WellNetwork 45 minutes after a medication was withdrawn from automated medication dispensing. (From Faces Pain Scale–Revised [FPS-R]. www.iasp-pain.org/fpsr. Copyright � 2001, International Association for the Study of Pain. Repro- duced with permission [Hicks, von Baeyer, Spafford, van Korlaar, & Goodenough, 2001])

216 Rao-Gupta et al.

about pain and pain management during their daily

rounds with the patients, families and health care

teams. During daily nursing leadership rounds, pa-

tients and caregivers were asked how well pain man- agement needs were being addressed. If pain was not

being addressed as expected by the patient and family,

the leader immediately contacted the appropriate

health care team members. The pain treatment plan

was then modified or corrective actions were taken,

and the patient and family were informed by the nurse

leader of the actions taken.

Pain Treatment Evaluation Pathway. The project team sought to integrate IPC with the automated medi-

cation dispensing system (AMD) and document actions

from both systems into the electronic health record

(EHR). The project team had to make several decisions

to design this workflow (Table 2).

Once the team designed new workflows, pilot

testing confirmed the pathway was triggered on

removal of as-needed analgesics from AMD. The sec- ond round of pilot testing verified that a pain reassess-

ment prompt appeared on the patient’s television

within 45 minutes and the pain reassessment entered

by the patient was documented in the EHR. Within

60 minutes of analgesic administration, the nurse is

to assess the effectiveness of the pain treatment.

Nurses were instructed to compare the reassessments

entered through IPC and compare it with the informa-

tion they gathered through direct patient assessment and communication with parents.

Staff Education and Pathway Implementation. Nursing staff on both pilot units were taught the work-

flow and new functionality of IPC. Principles of adult

learning were incorporated to enhance effective

communication and education. Unit-based nurse edu-

cators and IPC champions spent 10-15 minutes

educating each nurse to ensure that all necessary in- struction was completed and understanding was veri-

fied. On August 26, 2014, once all testing and

education was completed, the Pain Pathway was pi-

loted on the two study units. The Pain Pathway

included (1) new admission assessment questions,

(2) integration between IPC and AMD to trigger the

Pain Pathway; and (3) integration between IPC and

EHR to document patient or parent reported pain reas- sessment and treatment effectiveness (see Fig. 2).

Data Collection and Analysis The primary outcome measure of this performance

improvement initiative was the proportion of

TABLE 2.

Pain Treatment Evaluation Challenges, Decisions and Rationales for Those Decisions

Challenge Decision Rationale

What would trigger the Pain Pathway?

Limit triggering of Pain Pathway to the removal of PRN analgesics from AMD.

� Limit number of times patients on scheduled analgesics would be prompted to reassess pain and evaluate treatment effectiveness.

� The project team did not want to fatigue patients or families with too many on screen prompts.

What should the interval between PRN analgesic removal from AMD and time IPC prompts patient and parent for reassessment and evaluation of treatment effectiveness?

Set interval between PRN analgesic removal and IPC prompt to 45 minutes.

� Nurse reassessment goal was 60 minutes after the administration of an analgesic

� We wanted patient/parent to reassess pain and effectiveness of intervention before the nurse assessment of treatment effectiveness.

What measure should the patient and parents use to reassess pain and evaluate treatment effectiveness?

The Revised Faces Pain Scale (Hicks et al. 2001) with 11 options (0-10), even though the validated scale only includes even numbers corresponding to the 6 faces (see Fig. 4).

� The on-screen prompt provides limited space.

� The hospital uses five different valid and reliable pain scales to meet the varied developmental needs of patients served.

� Pain management champions were concerned that standard pain scales are not validated for parent-proxy reporting of children’s pain.

� There was no way to distinguish self-report from parent report through IPC in EHR.

How to reconcile self-report communicated verbally to the nurse and IPC reassessments documented in EHR?

Reassessments to be documented in EHR by the nurse based on the patient/parents’ feedback

� Both responses were reviewed by the nurse with appropriate intervention taken.

PRN ¼ as needed; AMD ¼ automated medication dispensing system; IPC ¼ interactive patient care; EHR ¼ electronic health record.

217Interactive Patient Care Technology Improve Pain Management

positive responses to the Child Hospital Consumer

Assessment of Healthcare Providers and Systems

(Child HCAHPS) (National Research Corporation,

2014-2016) question ‘‘Did staff do everything they

could to manage your child’s pain?’’ The percentage

is calculated as the proportion of patients who re-

sponded ‘‘always’’ out of all responses to this ques- tion. This HCAHPS question is included on the

patient experience survey mailed to families within

30 days of hospital discharge. However, patients hos-

pitalized on Hematology/Oncology Unit are surveyed

no more frequently than every 3 months. Far fewer

surveys are expected from the Hematology/

Oncology Unit than from the Pediatric Surgical

Unit because of the inherent differences in these

pilot unit patient volumes and the frequent repeti-

tive hospitalizations required by some Hematology/

Oncology Unit patient chemotherapy protocols.

Difference in proportion of positive responses on

the HCAHPS pain management satisfaction question

were evaluated with c2 tests and SPSS Software Version 17.0 (SPSS Inc., Chicago, IL). A minimum of 30 surveys were needed for each pilot unit at each

time point to analyze differences in proportions. Level

of significance was set at p < .05. Admission intake data acquisition was completed

within the first 24 hours of admission. Intake data were

audited on a monthly basis and included in raw data re-

ports requested from the Data Analytics and Reporting

team.

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218 Rao-Gupta et al.

Patient-generated pain reassessments were docu-

mented in the patient’s record in real time, within

the 45- to 60-minute window when the prompt ap-

peared on the patient’s TV screen (IPC). Nurses

continued to document pain assessments, treatments,

and effectiveness of treatments in the same manner

as before the pilot. The frequency of documentation was included in monthly raw reports from the Data An-

alytics and Reporting team. These data were then

further analyzed by the core project team and the

unit-based teams.

RESULTS

By the end of the first year of implementation, there

had been a steady increase in use of IPC and the Pain

Pathway. Specifically, the new admission assessment

questions were consistently completed by direct care

nurses (Fig. 5). Pain reassessment by patients and fam-

ilies through the Pain Pathway also steadily increased on both pilot units (Fig. 6). In addition, documentation

in the EHR of nonpharmacologic methods used to help

patients manage and cope with pain also increased

(Fig. 7).

Proportion of positive responses from patients

and parents on the Hematology/Oncology Unit signifi-

cantly increased from fiscal year 2014 (FY14) to fiscal

year 2015 (FY15) (p ¼ .036) and from FY14 to fiscal year 2016 (FY16) (p ¼ .028); but there was no differ- ence in the proportion of positive responses from

FY15-FY16 (p ¼ .87) or for each year compared with

FIGURE 5. - Documented responses for new

the CHA benchmark (FY14 p ¼ .255, FY15 p ¼ .32, FY16 p ¼ .26) (see Fig. 1). There was no significant dif- ference in the proportion of positive responses from

patients and families on the Pediatric Surgical Unit

(FY14-FY15 p ¼ .8, FY14-FY16 p ¼ .11, FY15-FY16 p ¼ .44); or for each year compared with the CHA benchmark (FY14 p ¼ .73, FY15 p ¼ .91, FY16 p ¼ .63). Finally, there was no significant difference in the proportion of positive responses from the com-

bined patients and parents of the two pilot units for

each year compared with the CHA benchmark (FY14

p ¼ .52, FY15 p ¼ 1, FY16 p ¼ .49); or from FY14- FY15 (p ¼ .2) and FY15-FY16 (p ¼ .27). However, the positive responses from the combined patients

and parents of the two pilot units significantly increased from FY14-FY16 (p ¼ .006).

DISCUSSION

The Pain Pathway pilot was initiated in response to a perceived disconnect among health care providers,

patients, and parents regarding the strategies and

effectiveness of pain treatment plans. The project

team’s commitment to provide tools to address

pain from admission through discharge helped to

standardize messaging among health care team mem-

bers. The commitment to engage patients and their

parents in conversations about pain also recognized the need to individualize communication about pain

expectations, treatment options, preferences, and

plans.

pain admission assessment questions.

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FIGURE 6. - Percent of patient and family responses to Pain Pathway evaluation of treatment effectiveness television prompts.

p ri n t & w e b 4 C = F P O

219Interactive Patient Care Technology Improve Pain Management

By leveraging IPC, patients and parents were engaged to take an active role in pain treatment plans

and evaluation of treatment outcomes. The increased

amount of documentation related to pain is both the

resultof theproject team’s innovative approachand their

commitment to facilitate conversation about pain. Thus,

FIGURE 7. - Total number of nonpharmacologic interventions FY14 ¼ fiscal year 2014, baseline measure; FY15 ¼ fiscal year 2 patients.

documentation of nonpharmacologic interventions increased even though this was not hard wired into the

workflow designs. This performance improvement proj-

ect, and other unit-based pain management initiatives,

improved active communication about pain and partner-

ship with patients and parents to effectively change the

documented for patients hospitalized on two pilot units. 015; FY16 ¼ fiscal year 2016. # Unique Pts. ¼ no. of unique

220 Rao-Gupta et al.

culture of the two pilot units to be more sensitive to chil-

dren’s pain and patient and parents’ hospital experi-

ences. HCAHPS scores significantly increased as a result.

Poor correlation between pain intensity and

patient-reported satisfaction with pain management

in hospitals is well documented, and explanations for

this dissonance are varied and complex (Golas, Park, & Wilkie, 2016). Recently, Centers for Medicare and

Medicaid Services (CMS) announced plans to remove

the pain management dimension from the scoring for-

mula used in the hospital value-based purchasing pro-

gram (CMS, 2017). However, CMS also announced

the pain management questions will remain on

HCAHPS and will continue to be publicly reported.

Despite the lack of evidence to support the value of this care quality measure, hospital administrators, as

well as nurses involved in pain management, seek to

satisfy patients’ and families’ expectations for pain

management and perceptions of the health care teams’

responsiveness to pain management. Documented

evidence-based interventions that improve patient-

and family-reported satisfaction with pain management

are needed. We reframed our approach to patient and family satisfaction as a patient and family engagement

and communication performance improvement proj-

ect. We have provided evidence that this intervention

increased patient and family satisfaction with pain

management as well as documentation of pain admis-

sion assessments, nonpharmacologic interventions,

and evaluation of treatment effectiveness (reassess-

ment) on our two pilot units. The Pain Pathway was implemented throughout

the hospital on all the inpatient units, except the

neonatal intensive care unit, on April 19, 2016. Expan-

sion of the project has promoted additional strategies

to engage patients, parents, and health care teams in

conversations about pain. For example, child life spe-

cialists now create action plans for patients who

need additional support. These plans include cues and suggestions, such as:

� When I am in pain, I may pinch, scratch or bite; � Counting and singing help me calm down when I am up-

set; or,

� If I am becoming tense, please remind me to squeeze my stress ball.

Child life specialists post action plans on patient

doors to cue health care team members before they

enter the patient’s room. Partnering with child life spe- cialists has been instrumental for increasing pain

awareness and identifying additional techniques to

reduce pain and strategies to promote patients’ and

parents’ abilities to cope during hospitalization.

Limitations There are several limitations to the Pain Pathway work-

flows. The Pain Pathway is triggered by the removal of

an as-needed analgesic from the AMD, and the patient is prompted to reassess pain and evaluate treatment

effectiveness 45 minutes later. There can be a delay

from the time the medication is removed from the

AMD until the medication is given to the patient.

Consequently, the patient may be prompted to reassess

his or her pain and evaluate the effectiveness of the

intervention before the reasonable onset or peak anal-

gesic effect. Once the Pain Pathway has been triggered by the removal of the medication from the AMD, it

cannot be stopped or cancelled. If the patient later re-

fuses the medication, reassessment will still be promp-

ted 45 minutes after the removal of the medication

from the AMD. As-needed analgesics, like acetamino-

phen, are also indicated for fever. Unfortunately, the

medications that trigger the Pain Pathway are identified

by as-needed status and name, not by as-needed indica- tion. There is no way to identify at the time of removal

from AMD, or in the EHR, that the as-needed medica-

tion is being administered by the nurse for other valid

reasons.

Implications for Nursing Practice Based on the outcomes measured and feedback gath-

ered from staff and families over the course of this

initiative, the findings suggest that using multiple mo-

dalities is essential to effectively engage parents/care- givers in their child’s care. A multidisciplinary team

that communicates a consistent message about part-

nership and decision making is integral in shifting the

culture around pain management to be more patient-

centric. Truly listening to the patient and family is para-

mount in creating an effective and individualized plan

of care. Furthermore, finding additional ways to

harness technology and connect unique systems will assist in building a more comprehensive picture of pa-

tient and family preferences, which in turn must

continually be incorporated into care team recommen-

dations to move patient care forward in a meaningful

way.

CONCLUSIONS

This innovative performance improvement project has had a positive impact by engaging patients, families,

and health care team members to partner in managing

pain. Reframing our approach for improving patient

and family satisfaction with pain management by

leveraging IPC to engage patients and families in pain

221Interactive Patient Care Technology Improve Pain Management

care planning was effective. Patient and family satisfac-

tion with pain management improved, and documenta-

tion of pain admission assessments, nonpharmacologic

interventions, and evaluation of treatment effective-

ness (reassessment) improved. Additional testing of

this intervention through replication at other hospitals

is needed to provide further evidence of the effective- ness of this approach.

When the mother of a surgical patient was inter-

viewedregardinghospitalexperiencesand communica-

tion with the health care team about pain management,

she stated:

‘‘Being diagnosed with something that isn’t very

common is scary.. As a parent, you want to comfort, and make him feel better. It’s nice to know that the people here are doing what I can’t do to make him

feel better. To manage his pain, it seems that they are

just as concerned as I am; it’s comforting to know

that they’re watching it really close and doing what

they need to, to help. The doctors and nurses keep

me very involved in the steps that they are going to

take to help manage his pain.so it’s really nice to be kept in the loop with not just his medications, but the other things that they are doing to help him. I’m

really glad we’re here.’’

Acknowledgments

The authors would like to thank the departments of nursing,

clinical and organizational development, information tech-

nology, nursing informatics, and pharmacy for their dedi-

cated effort to this project.

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