IN BRIEF

A Painful Reality: Care Providers Tend to Underestimate Pain During Pediatric Burn Dressing Changes

September 13, 2016
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Researchers call for an updated pain scale.

Dressing changes have been identified as one of the major contributors to perceived pain during burn care, and so it is important that pain be assessed accurately. But a new study from the Center for Pediatric Trauma Research in The Research Institute at Nationwide Children’s Hospital suggests that pediatric burn pain assessment can vary based on not only patient pain intensity but also nurse clinical experience.

A measurement tool called the Face, Legs, Activity, Cry, Consolability Scale (FLACC) is widely used by nurses to rate pain in pediatric patients. It can be applied to pediatric patients of all ages, including the very young, so it provides a standard assessment for all patients in our pediatric burn center. This study found that nurses tended to underrate both mild and severe procedural pain. Nurses who had less nursing experience demonstrated significantly higher accuracy than those with more experience.

“This is concerning because it demonstrates that on a well-established burn unit that specializes in caring for pediatric patients, nurses may too often underrate children’s procedural pain for both mild and severe pain,” says Jonathan Groner, MD, senior author of the study, medical director of the Center for Pediatric Trauma Research and affiliate faculty of the Center for Injury Research and Policy in The Research Institute.

Jiabin Shen, PhD, postdoctoral fellow for the Patient-Centered Pediatric Research Program in the Center for Pediatric Trauma Research in The Research Institute and the study’s lead author, also noted concern that “new” burn nurses (less than 5 years nursing experience) appeared to be more accurate in FLACC rating than more experienced nurses.

This study, available now online and in the September issue of Burns, is the first study to systematically examine FLACC rating accuracy among care providers. Developed in 1997, the FLACC scale was originally designed to measure post-operative pain in pediatric populations. The FLACC utilizes an easy-to-understand 0-10 metric and exerts a relatively low burden on medical staff. It has previously demonstrated a high level of inter-rater reliability and concurrent validity with other existing scales. But much of the previous research was not in clinical settings.

“Our findings suggest that patient pain intensity and nurse clinical experience are two significant contributors to rating accuracy,” says Dr. Groner. “But additional research is needed before generalizing the findings to other medical staff populations, medical procedures, and factors.”

Dr. Groner and the burn team suggest a multidisciplinary approach utilizing child life specialists, parental participation, and pharmacologic agents to alleviate pain during burn dressing changes.  “We are pursuing the development of a new pediatric pain scale,” he says.