Implementation of the revised-FLACC Observational Pain Scale on a Pediatric Unit

Abstract

Problem: Children with developmental delays, cognitive impairments, and intellectual disabilities are more likely to receive pediatric specialty care leading to frequent hospitalizations and surgeries. This population has atypical pain behaviors and cannot self-report pain; therefore, they are at risk for the under recognition and treatment of pain. In a large academic hospital, a pediatric inpatient unit has a high population of children meeting this criterion. The current standard pain assessment for patients unable to self-report is the FLACC scale; however, the revised-FLACC (r-FLACC) is tailored to assess pain in this population and offers the opportunity for parent or caregiver input. Purpose: The purpose of this quality improvement project was to implement and evaluate the r-FLACC pain scale for assessing pain in pediatric patients with developmental delays, intellectual disabilities, and cognitive impairments. Methods: The practice change took place over 15 weeks on a pediatric medical-surgical unit. Nursing utilized the r-FLACC pain scale to quantify eligible patients’ pain every four hours with parental involvement. Data collection included nursing compliance with the r-FLACC, parent or caregiver opportunity to individualize the pain scale on admission, r-FLACC scores, and pain interventions. Parent and caregiver perception of the child’s pain assessment using the r-FLACC was assessed upon discharge anonymously. FLACC scores concurrently recorded in the electronic medical record by nurses were extracted and compared to r-FLACC scores. Results: During implementation approximately three (15%) patients a day qualified for use of the r-FLACC pain scale. There were 465 observations for which both the FLACC and r-FLACC were collected across 15 patients. The r-FLACC pain scores were similar and often higher than concurrent FLACC scores. Discharge surveys revealed parents and caregivers were satisfied with the r-FLACC pain scale and their child’s pain management and treatment. Conclusions: The r-FLACC scale adequately captured this pediatric population’s pain and caregivers were satisfied with their child’s pain management. The r-FLACC pain scale provided an opportunity to better recognize and treat pain in this population. Next steps include integration of the r-FLACC pain scale in the electronic medical record to be used in all pediatric areas.