1. Case Study Mary has just graduated from a BSN program. She has been offered a job on the pediatric unit at a small rural hospital. Although the hospital only has 65 beds, it does have a unit reserved for pediatric patients. Shortly after being hired to work on the pediatric units, Mary discovered that the staff used the FACE pain assessment tool for all patients on the unit. During her BSN program, Mary was familiar with the FLACC pain assessment tool. Mary is unsure as to which tool is the most valid and reliable for small children. EBP: Evaluation of Pain Assessment Tools in a Pediatric Population

2. Patient Group Focus Question The purpose and goal of this query is to determine which pain assessment tool is more reliable when caring for pediatric patients in a rural hospital. The focused question is to determine what the highest level of evidence is that we have available in understanding whether the FACE or FLACC pain assessment tool is the best method to quantify pain of a pediatric population in a rural hospital.

3. Targeted Resources The EBP team decided to search for the best evidence related to pain assessment tools in a pediatric population. We opted to use resource databases available to us such as CINAHL, Cochrane Library, and ProQuest. These sources were chosen because of their accessibility, quality, and trustworthiness.

4. The Search After deciding upon reference databases, the team developed a focused question to guide the search. The question was developed using the PPAARE method. The problem is the reliability and validity of pain assessment tools. The patient is of pediatric age (newborn to18 years) in a rural hospital. The action to be taken is diagnostic intervention regarding pain assessment using the FLACC tool, and the alternative is using standard diagnostic intervention using the FACE tool. The patient result of this study is to use the more accurate assessment of pain for pediatrics.

5. PPAARE Question: Focused Query Question Problem Pain Assessment tool validity and reliability PatientPediatric Patients in Rural Hospital Action Diagnostic intervention regarding pain assessment using the FLACC tool Alternative Standard diagnostic intervention using the FACE tool Patient ResultsAccurate assessment of pain Level of EvidenceCase studies, case reports, editorials, expert opinions

6. Relevant Evidence We reviewed the research and conclude that both the FLACC and the FACE are valid and reliable tools in pain assessment of a pediatric population. According to evidence-based research, however, FLACC is the most appropriate and reliable pain assessment tool for children less than 3 years of age.

7. Analysis of the Evidence Reference 2 : Mixed Method Study Critique: Strong for tools, however, not meeting our qualification for setting. Reference 3: Mixed Method Study Critique: This a complex issue when different strategies have been used prior to the implementation of these assessment methods.

8. Analysis of the Evidence, Cont… Reference #4: Mixed Method study Critique: The FLACC is as valid as a common 0 to 10 pain rating scale (such as the FACE). Reference #5: Qualitative study Critique: Study could have been expanded to a larger population sample over a greater period of time. Results uphold reliability and validity of both tools.

9. Evidence Appraisal Qualitative Study: Summary relatable to Reference # 5 The FLACC is a valid tool as a measure in post-op pain in a pediatric population. Disparities between self-report (FACES) and FLACC apparent for children aged 3 -4 however do not influence the overall usefulness of these tools in this population. Using these tools as a component to pain assessment assists in making decisions regarding pain management in children.

10. Evidence Appraisal cont… Quantitative Study : Summary relatable to Reference # 3 This study demonstrates some of the complexities of managing children’s pain and the obstacles to implementing change. The increase in the use of the tool to 40 percent of children 12 months post-implementation demonstrates a determination of many nurses to deliver evidence- based care despite the obstacles.

11. Conclusion Both the FLACC and FACES are reliable and valid assessment tools in a pediatric population in a rural hospital setting, however, the FLACC tool offers a greater population application.

12. What we chose to do in reference to the case study… Based upon this evidence, we chose to incorporate the FLACC assessment tool to quantify pain in our target population. –Upon implementation of the FLACC assessment tool, the staff required education regarding the implementation of a new pain assessment tool. –A review of this change occurred at the six-month post-implementation mark. some staff were unprepared to document appropriately when using this new tool for a time of up to 6 months post implementation. –Consistent and recurrent education is needed post implementation to increase overall compliance –Visual aids were placed above every bed so that patients could refer to the assessment tool and ask questions should any arise. –Particular pain intervention protocols were discussed with the family –Many parents who assisted in reporting pain of their children were educated as to how the FLACC tool assisted the clinical staff –We measured outcomes in two ways. We surveyed the clinical staff at the three-month post-implementation mark as well as the 9-month post-implementation mark We sent questionnaires to the parents of each pediatric patient post-discharge

13. Wong – Baker FACES Pain Scale

14. FLACC: our preferred tool

15. References Howlett, B., Rogo, E.J., and Shelton, T.G. (2014) Evidence-based Practice for Health Professionals: An Interprofessional Approach. Burlington, MA: Jones & Bartlett Learning. Shavit. I., Kofman, M., Leder, M., Hod, T., & Kozer, E. (2008). Observational pain assessment versus self-report in paediatric triage. Emergency Medicine Journal, 25(9), 552-555. doi: 10.1136/emj.2008.058297 Simons, J., & Macdonald, L. (2006). Changing practice: implementing validated paediatric pain assessment tools. Journal of Child Health Care, 10(2), 160-176. doi: 10.117/1367493506062555 Voepel-Lewis, T., Zanotti, J., Danmeyer, J., & Merkel, S. (2010). Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. American Journal of Critical Care, 19(1), 55-62. doi: 10.4037/ajcc2010624 Willis, M., Merkel, S., Voepel-Lewis, T., & Malviva, S. (2003). FLACC Behavioral Pain Assessment Scale: a comparison with the child’s self-report. Pediatric Nursing, 29(3), 195-198.