Patient Safety Project:
Assessing the Use of Pain
Medication Post Pediatric
Cardiac Catheterization
Emily F. Moore RN, MSN, CCRN, CPNP-PC
Heart Center, Seattle Children’s Hospital
Disclosure statement
I do not have any relevant financial
relationships with any commercial
interests to disclose
Problem Identification
• Cardiac catheterizations cause stress to patients and
families
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Little data exists regarding immediate post cardiac
(rounded
catheterization pain
corners
optional)
• Data is scarce related to pain post discharge
Significance
• Congenital heart disease effects 8 per 1000 live births
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• Approximately 2 to 4 of these infants require cardiac
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catheterization and/or cardiac surgery
(rounded
corners
optional)
• The complication rate is low
• Adverse events are defined as any anticipated or
unanticipated event caused by a cardiac
catheterization
Purpose
• The purpose of our study was to determine if pain after
an outpatient invasive catheter based procedure was
clinically important.
Specific Aims
• Describe pain reported post cardiac catheterization
• Describe medication usage post cardiac
catheterization
• Describe the adequacy of analgesics used
• Examine factors associated with inadequate
analgesics
Quality Improvement Study
• Expedited as a result of a sentinel event
• Prompted a thorough evaluation of policy and procedure
regarding treatment of acute post procedural pain
• Directly effected pain management in the cardiac
catheterization labs
What we know about pain
• A subjective experience described as an unpleasant
sensory and emotional experience associated with
tissue damage. In conjunction with any medical
intervention that may be potentially painful or cause
anxiety can be referred to as procedural pain
• Psychological effects of poor pain management in
children may have significant life long damage
Methods
• Design:
• Prospective cohort study using a phone survey
• IRB exemption was obtained
• Subjects:
•
All cardiac catheterization patients ranging from day 1 of life to
23 years old (excluded ICD and pacemakers)
Methods
• Setting:
• Tertiary care center serving the WWAMI region
Methods
• Instruments:
• Questionnaire designed to asses post cardiac catheterization pain
• Wong Baker FACES scale
Procedures
• Nurses attended a training specific to pain assessment
• Standard procedure was implemented regarding follow up phone
calls
• Patients and families were assessed pre-operatively regarding
ability to rate pain
• Patients and families were informed they would receive a phone
call at 1-2 days post procedure to follow up and assess pain
Data Analysis
• Patients were broken into two groups
• Those who experienced pain
• Those who did not
• SPSS statistical software was used to evaluate data
• Fisher’s exact test
Results
Demographics and case detail
n (%)
Total number of procedures
1045
Total number contacted
745 (72)
Gender
Male
409 (55)
Ethnicity
Caucasian
581 (78)
African American
60 (8)
Asian American
60 (8)
Native American
30 (4)
Other
15 (2)
Diagnostic
231 (31)
Interventional
395 (53)
Electrophysiology
120 (16)
Arterial
417 (56)
Venous
731 (98)
Type of procedure
Access
Results
• 72% responded by phone 48 hours after procedure
• 98% (731) experienced no pain or pain relieved by
acetaminophen
Results
• 14 patients had pain unrelieved by acetaminophen
• Seven (7) complained of generalized discomfort related to
procedural positioning (lying flat) for several hours
• Nearly half had important complications at the site of vascular
access
• Six (6) with hematomas at the access site
• One (1) with pseudoaneurysm
Results
• Based on a Fisher’s exact test, post procedural pain
unrelieved by acetaminophen had a statistically
significant association with complications at 0.02% (p
<0.01)
Discussion
• Pain was typically mild
• Pain unrelieved with acetaminophen could be an
indicator for complications
• The importance of pain may have been missed had
opioids been prescribed without evidence of need
• A large number of patients avoided unnecessary
exposure to opioids
Conclusion
• Opioid use following a pediatric cardiovascular invasive
procedure is not required and if utilized may mask
clinically important pain
• A pseudoaneurysm may had been missed had this
project not been initiated and the patient been sent
home with an opioid prescription
Practice Change
• Families were provided with detailed instructions
regarding new process
• A phone survey was designed and implemented
• Efforts were focused on actual patient need versus
varied opinions regarding perceived pain
• Through CPI we knew, any patient identified to have
pain unrelieved by acetaminophen needed to be
immediately discussed with the team
Recommendations moving forward
• All patients should receive close follow up
• Importance should be placed on same day procedures
• Acetaminophen should be sufficient to treat pain
• Any patient who reports pain unrelieved by
acetaminophen should be assessed by the healthcare
team
Acknowledgements
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•
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Jack Salerno MD
Arlene Armatage RN
Jenny Keylon RN
Karen Thomas
References
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Thanks!