JBUR-4460; No. of Pages 7 burns xxx (2014) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines Hejdi Gamst-Jensen a,*, Pernille Nygaard Vedel b, Viktoria Oline Lindberg-Larsen a, Ingrid Egerod c,d a
Department of Anesthesiology, Copenhagen University Hospital, Bispebjerg, Copenhagen, Denmark Department of Orthopedic Surgery, Copenhagen University Hospital, Bispebjerg, Copenhagen, Denmark c Faculty of Health & Medical Sciences, University of Copenhagen, Denmark d Trauma Centre, Copenhagen University Hospital Rigshospitalet, Denmark b
article info
abstract
Article history:
Objective: Burn patients suffer excruciating pain due to their injuries and procedures related
Accepted 22 August 2014
to surgery, wound care, and mobilization. Acute Stress Disorder, Post-Traumatic Stress Disorder, chronic pain and depression are highly prevalent among survivors of severe burns.
Keywords:
Evidence-based pain management addresses and alleviates these complications. The aim of
AGREE instrument
our study was to compare clinical guidelines for pain management in burn patients in
Burns
selected European and non-European countries. We included pediatric guidelines due to the
Clinical guidelines
high rate of children in burn units.
Pain management
Method: The study had a comparative retrospective design using combined methodology of
Pediatrics
instrument appraisal and thematic analysis. Three investigators appraised guidelines from burn units in Denmark (DK), Sweden (SE), New Zealand (NZ), and USA using the AGREE Instrument (Appraisal of Guidelines for Research & Evaluation), version II, and identified core themes in the guidelines. Results: The overall scores expressing quality in six domains of the AGREE instrument were variable at 22% (DK), 44% (SE), 100% (NZ), and 78% (USA). The guidelines from NZ and USA were highly recommended, the Swedish was recommended, whereas the Danish was not recommended. The identified core themes were: continuous pain, procedural pain, postoperative pain, pain assessment, anxiety, and non-pharmacological interventions. Conclusion: The study demonstrated variability in quality, transparency, and core content in clinical guidelines on pain management in burn patients. The most highly recommended guidelines provided clear and accurate recommendations for the nursing and medical staff on pain management in burn patients. We recommend the use of a validated appraisal tool such as the AGREE instrument to provide more consistent and evidence-based care to burn patients in the clinic, to unify guideline construction, and to enable interdepartmental comparison of treatment and outcomes. # 2014 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: Department of Anesthesiology, Copenhagen University Hospital, Bispebjerg, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark. Tel.: +45 35313531; fax: +45 35312966. E-mail address: [email protected] (H. Gamst-Jensen). http://dx.doi.org/10.1016/j.burns.2014.08.020 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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1.
Introduction
Burn is the 11th most frequent cause of death in childhood (age 1–9 years), and yet despite of the magnitude of the problem appropriate treatment of burn related pain remains an issue [1]. The degree of the burn, the person affected, and the sensory input act as mediators of the pain perception [1]. The pain varies by the depth of the skin lesion and the inflammatory response; initially the more superficial, the more painful. Burns have been classified into three groups based on their vertical spreading [2]: First-degree burns affecting epidermis, second-degree burns involving epidermis and part of dermis, and third-degree destroying epidermis and dermis. Free nerve endings add to the pain experience and while full thickness burns are initially numb, subsequent nerve regeneration might cause neuropathic pain [1,2]. The subtypes of burn related pain are: background pain, breakthrough pain, procedural pain, and postoperative pain [3]. All stages of burns might be present in the same individual, making the pain-level difficult to assess and increasing the risk of excessive or inadequate treatment. Varying etiologies and intensity of pain demand individual and flexible pain management. The long-term risk of undertreated pain is the development of chronic pain, depression and Post Traumatic Stress Disorder (PTSD) [1]. Studies show an alarmingly high prevalence of chronic pain, Acute Stress Disorder (ASD) and depression among individuals who have suffered severe burns [4–6], rendering the issue of pain management essential in modern burn care. The European Burn Association encourages its members to develop and share clinical guidelines in order to move from a clinical practice dominated by personal experience to evidence-based and cost effective practice [7]. The aim of our study was to compare clinical guidelines for pain management in burn patients in selected European and non-European countries. We included pediatric patients due to the high rate of children in burn units.
2.
Method
2.1.
Materials and methods
The study had a comparative retrospective design triangulating instrument appraisal and thematic analysis. In 2013 we contacted seven burn units in Denmark, Sweden, New Zealand and USA to recruit material for our study. The countries were convenience sampled selected for being comparable Western countries using either English or one of the Scandinavian languages, and the departments were selected on the basis of personal knowledge and a literature search. Initial contact was made to head physicians and subsequently to nurse managers, clinical specialists and other physicians by telephone or email. We accepted clinical guidelines, protocols or pathways and chose to refer to any of these instruments by the general term of ‘guideline’ in this study. We included guidelines that (a) provided references and (b) were updated within the past five years (Fig. 1). Four clinical guidelines met the criteria and were included in the study. The clinical guidelines were appraised using to the AGREE instrument (Appraisal Guidelines for Research and Evaluation) version II [8], and subsequently we performed a thematic text analysis to describe central themes in the guidelines. The appraisal by the AGREE instrument was carried out by 3 appraisers who assessed all domains and items in every guideline. The thematic analysis was performed by the corresponding author assisted by the last author.
2.2.
Strategy of analysis (guideline appraisal)
The AGREE Instrument is an internationally developed and tested appraisal instrument for assessing the quality of clinical guidelines; also providing a methodological strategy for the development of guidelines, and informing about the type of information to be included in the guidelines [8]. Clinical guidelines should be validated both internally and externally, and should be easy to use in practice. The AGREE instrument
Fig. 1 – Flow-chart of inclusion. Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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Table 1 – The AGREE instrument. Domains 1. Scope and purpose 2. Stakeholder involvement 3. Rigor of development
4. Clarity of presentation 5. Applicability
6. Editorial independence
Overall assessment
Assessment The overall objective, population and health question is clearly described. The involvement of all relevant professional groups and target population has been sought and clearly defined. Systematic literature search with grading of evidence of the selected literature. Strength, limitations and methods for formulation the recommendations are clearly described. Explicit link between evidence and recommendation. Externally reviewed by experts and has a procedure for updating. Provides specific and unambiguous recommendations. Different treatment options are clearly presented and key recommendations are easily identifiable. Describes facilitators and barriers to application as well as tools to implementation. Resources in applying recommendations have been considered. Monitoring and audit criteria are present. Funding body has not influenced the content and competing interests of developmental groups were addressed.
3 3
Overall quality and recommendation.
2 n = 23
does not assess the clinical content, quality of evidence, or impact on patient outcome, but can be used to test and compare clinical guidelines for consistency and quality. Guideline appraisal also includes judgment about the methods used for guideline development, timing of updates, and economic and editorial independence. The AGREE instrument includes six domains and two global rating items (overall assessment) addressing 23 items to be assessed in the guideline (Table 1). The domains are: 1. Scope and purpose; 2. Stakeholder involvement; 3. Rigor of development; 4. Clarity of presentation; 5. Applicability; and 6. Editorial independence. Each item is graded on a 7-point scale and domain scores are calculated by summing up the scores of the items in a domain and by scaling the total as a percentage of the maximum possible score for that domain. It is recommended that the appraisal is conducted by 2–4 appraisers to ensure reliability and validity. Domain scores are calculated by summing up all the scores of the individual items in a domain and by scaling the total as a percentage of the maximum possible score for that domain. The scaled domain scores are calculated as ‘‘obtained score minus minimum possible score’’ divided by ‘‘maximum possible score minus minimum possible score’’. Inter-rater correlation was assessed using Cohen’s Kappa.
2.3.
Number of items
Strategy of analysis (thematic analysis)
We performed a thematic analysis of the four guidelines to identify core themes [9]. We performed vertical analysis of each guideline to identify the themes, followed by horizontal analysis of each theme across the sample. Our initial strategy was deductive coding according to themes found in the literature (preliminary template). This was followed by
8
3 4
2
inductive coding to identify emerging themes in the sample (development of a category scheme). Finally, we compared the four guidelines by recording the presence or absence of the selected core themes in the guidelines.
2.4.
Ethical considerations
The study complied with the principles of the Helsinki declaration. All participation was informed and voluntary. No patients were involved.
3.
Results
The four guidelines were selected from university hospitals with specialized burn units in Denmark (DK), Sweden (SE), New Zealand (NZ) and USA (Table 2). The Danish guideline was compiled from several sources representing the instruments used by the clinicians at the unit: a specific pathway for burn care at the unit and a general guideline for pain management at the hospital. The Swedish guideline was part of a 125-page booklet: Compendium of burns. It was stated in the introduction that the purpose of the booklet was to create order in the chaos of available options and individual needs in burn patients. The New Zealand guideline was a 114-page booklet; an evidence-based best practice guideline providing a comprehensive guide to burn care [10]. A multidisciplinary team of practitioners authored the guideline. An additional five protocols and pathways provided a hands-on approach to pain management and assessment. The American guideline was based on a textbook (Total Burn Care, chapter 64), authored by a co-author of the guideline [2]. The evidence in
Table 2 – The structure of the guidelines. Denmark Local pathway for burn care + general hospital guideline for pain
Sweden
New Zealand
USA
Compendium of burns (125 pages)
Best practice guideline (114 pages) + 5 protocols and pathways for pain
Guideline + textbook chapter (evidence-based and referenced)
Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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Table 3 – Detailed appraisal of the guidelines using the AGREE instrument. Domains 1. 2. 3. 4. 5. 6.
Scope and purpose Stakeholder involvement Rigor of development Clarity of presentation Applicability Editorial independence
Overall assessment Recommendation
Denmark
Sweden 78% 59% 13% 20% 19% 11%
87% 85% 79% 76% 63% 89%
83% 59% 63% 81% 76% 64%
22% Not recommended
44% Recommended with modifications
100% Strongly recommended
78% Strongly recommended
Appraisal using the AGREE instrument
The guidelines from Sweden, New Zealand and USA had similarly high scores in Domain 1 (Scope and purpose), respectively 78%, 87%, and 83%, whereas Denmark had only 37% (Table 3). In Domain 2 (Stakeholder involvement) we found more variation: DK (17%), SE (59%), NZ (85%) and USA (59%). Domains 3, 4, and 5 (Rigor of development, clarity of presentation, and applicability) were lower in Denmark and Sweden than NZ and USA. Domain 6 (Editorial independence) followed a similar pattern: DK (3%) and SE (11%) than NZ (89%) and USA (64%). The overall assessment demonstrated a wide span of variability: DK (22%), SE (44%), NZ (100%) and USA (78%). The guideline from New Zealand was professionally written, including a statement of editorial independence in the introduction. The American guideline was dependent on the evidence published in the accompanying textbook chapter, and editorial independence was not clearly discussed in Danish and Swedish guidelines. Inter-rater correlation was assessed using Cohen’s Kappa after grouping the outcomes into three major categories (1–3), (4–5) and (6–7); the result was moderate inter-rater correlation of 0.54, 0.57, and 0.59 respectively.
3.2.
USA
37% 17% 10% 11% 10% 3%
the guideline referred to the textbook. The guideline was used in a pediatric burn unit.
3.1.
New Zealand
Thematic analysis
After rating the guidelines according to the AGREE instrument, we conducted a thematic analysis. The following core themes were identified: continuous pain, procedural pain, postoperative pain, pain assessment, and anxiety. Another four themes were identified in the NZ and USA guidelines: itching,
procedural sedation, in-hospital physical therapy, and postoperative reconstructive surgery. We did not regard these themes as core themes to pain management, and they were not included in the Danish and Swedish guidelines. After selecting the core themes, we compared the four guidelines by recording the themes as present (+), absent ( ) or briefly mentioned (+/ ), Table 4. The degree of detail and evidence-base varied across the four guidelines. In the following, we compare the main themes in the guidelines (Table 5).
Continuous pain (background pain): The DK guideline offered no recommendations; the SE guideline recommended acetaminophen or NSAID (Non-steroid antiinflammatory drugs); the NZ guideline recommended acetaminophen, NSAID or morphine, and finally, the USA guideline recommended acetaminophen, NSAID, morphine or methadone, and included special rules for small children. Procedural pain: The DK guideline recommended analgesics or visualization (non-pharmacologic intervention), the SE guideline recommended general anesthesia for initial wound care, the NZ guideline provided handy flowcharts for the administration of morphine and nitrous oxide (Entonox), and the USA guideline recommended a variety of pharmaceuticals. Postoperative pain: All the guidelines recommended opioids for postoperative care. Anxiety: Three guidelines (SE, NZ and USA) addressed anxiety. Non-pharmacological interventions were recommended by three guidelines (DK, NZ and USA). The SE guideline recommended multidisciplinary rounds with a psychiatrist once a week.
Table 4 – Presence and absence of selected core themes.
Background pain Procedural pain Postoperative pain Pain assessment Anxiety Non-pharmacological intervention
Denmark
Sweden
New Zealand
USA
+/ +
+ +/ +/ +
+ + + + + +
+ + + + + +
+ +/
(+) Theme is present, ( ) Theme is absent, (+/ ) Theme is briefly mentioned in the guideline.
Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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Table 5 – Thematic content of the guidelines. Core content
Denmark
Sweden
New Zealand
USA Acetaminophen, NSAID, morphine, methadone. Restrictions if morphine is given to children 5 years
Continuous pain at rest
Not addressed
Acetaminophen NSAID
Acetaminophen, NSAID, morphine
Procedural pain
Analgesics as ordered
General anesthesia for initial wound care
Pain level not to exceed VAS >5
Postoperative pain
Acetaminophen, morphine, ketamine, trans-mucosal fentanyl, PCA in children >5 years
Acetaminophen, morphine, nitrous oxide, fentanyl, ketamine
Pain assessment Anxiety
Acetaminophen, NSAID, morphine, peripheral blocks, PCA in children >5 years VAS, FLACC Not addressed
Not addressed Clonidine, propofol, midazolam
Addressed Midazolam
Non-pharmacological intervention
Brief mention of visualization
Not addressed
Addressed
Wong-Baker Face scale (1–5), OPAS, VAS Lorazepam, diazepam Always add anxiolytic medicine to pain medicine when preforming wound care Addressed, several suggestions given, e.g. coping skills or hypnotherapy
NSAID: non-steroid anti-inflammatory drugs; PCA: patient controlled analgesia; NCA: nurse administered analgesia; OPAS: objective pain assessment scale; VAS: Visual Analog Scale; FLACC: Face, Legs, Activity, Crying, Consolability 0–10 scale; Wong-Baker Face scale: six images depict increasing degrees of distress.
4.
Discussion
The aim of our study was to compare clinical guidelines for pain management in burn units in selected European and non-European countries. Our main finding was the wide variability in pain management and differences in the clinical decision tools in our sample. In general, the guideline from New Zealand was the most sophisticated as it had been developed as an evidence-based guideline with associated protocols and pathways. The American guideline was less integrated, and relied on evidence from a textbook. Textbooks (background literature) are inherently less updated and evidence-based than published papers (foreground literature). The Danish and Swedish guidelines were the least comprehensive. We believe our study is the first to appraise guidelines on pain management in burn patients with the AGREE II instrument. By using the instrument we were able to compare different guidelines and describe the variation in evidencebased practice and core content. The four guidelines varied dramatically regarding management of background, procedural, and postoperative pain and anxiety. Two of the guidelines failed to comply with the standards suggested for clinical guidelines by AGREE. The thematic analysis of the guidelines served to illustrate the variability of areas addressed in burn care, whereas the assessment by the AGREE instrument addressed the variability of quality and consistency within the guidelines. Multimodal analgesia has been recommended for moderate to severe burn [11]. The principle is balancing systemic and regional medications to obtain optimal short and long-term pain relief, and the best combination of agents for posttraumatic analgesia still needs further investigation. Protocols vary on the administration of multimodal analgesia including oral analgesics (e.g. paracetamol) for low to moderate pain to intravenous opioids (e.g. morphine, tramadol, phentanyl) in
continuous perfusion or patient controlled analgesia (PCA) in severe pain, in some cases combined with benzodiazepines and hypnotics [12]. A survey has shown that optimal management of anxiety and pain reduces ASD [13], suggesting that long-term consequences of burns can be reduced. Persistent pain, depression and PTSD are highly prevalent in burn victims [5], and a study shows that in pediatric burn victims (2–48 months) there is an association between the extent of the burn, the heart rate, the pain level, and the parents’ reactions to the pain experienced by the child [4]. Another association was found between pain and ASD during the peritraumatic period (0–48 h post trauma) and the development of PTSD [6]. These studies support the need for addressing anxiety as well as pain. Several studies have shown that pain at rest and procedural pain vary in quality, intensity and duration [3]. For this reason shorter acting analgesics are recommended for wound care. More studies are suggesting non-pharmacological pain management including hypnotherapy, massage, distraction, virtual reality, and active coping [2,14], which demonstrates the need for integrating non-pharmacological solutions in clinical guidelines [15]. The guidelines from Denmark, New Zealand and USA included non-pharmacological suggestions for children, e.g. the American guideline referred to Child Life Therapy Department of Psychology for teaching and development of coping skills, and the New Zealand guideline referred to a Hospital Play Specialist Team to support the patients and caregivers during procedures. Other non-pharmacological options included therapeutic touch, cognitive enhancement, hypnotherapy, and virtual reality [2,16–18]. As suggested in a trial protocol for a virtual reality tool, there might be a link between reduced pain, stress and anxiety and improved healing time in acute burn wounds [19]. This underlines the need for incorporating non-pharmacological tools in a clinical guideline.
Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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The Swedish, New Zealand and USA guidelines considered the long-term effect of suboptimal pain management, and the Swedish unit offered weekly multidisciplinary patient assessment, including psychologist and psychiatrists. According to the AGREE instrument ‘editorial independence’ refers to the degree of influence from the funding body on the development of the guideline [8]. Also, it indicates that the particular interests of the guideline developers have been recorded and addressed. In the Scandinavian welfare system healthcare is financed through taxes, however, in recent years the welfare system has been threatened by globalization, which means that funding has been less generous than earlier [20]. The Danish and Swedish scores in editorial independence might indicate greater editorial independence compared to other countries that depend financially on private medical insurance. Competing interests of the developers, however, might still exist. The therapeutic effect of protocolled practice is supported in the literature [13,21,22]. Factors that influence implementation of guidelines are available resources, quality assurance, and belief in benefits of guidelines [23]. A meta-analysis identified management support, learning environment, functional differentiation and local consensus as important issues in guideline implementation [24]. Guideline development does not suffice without an implementation strategy. A variety of options are available in pediatric pain management, but each department should not attempt to implement too many interventions at once. We have discussed the importance of evidence-based practice and have pointed to a number of core issues that need to be dealt with when treating burn patients (e.g. anxiety, acute pain, procedural pain, itching). The AGREE instrument provides an excellent framework for constructing and appraising evidence based guidelines; moreover the process might lead to more uniform guidelines, thus enabling interdepartmental comparison of treatment and outcomes.
4.1.
Limitations
The AGREE-instrument is tool for the development and appraisal of clinical guidelines. In using three appraisers in our study we complied with the recommendations of the AGREE instrument. We used a broad definition of a guideline including protocols, pathways and clinical guidelines, which has probably limited the comparability of the instruments and the transferability of our results. The guidelines we assessed did not recognize the clinician– patient dyad as the decision-making unit. It is important in future studies to address the degree of collaboration between patient and professionals. Our study had a unilateral focus on pain without describing the context, i.e. the strategy of burn treatment. Different treatment modalities (e.g. hydrotherapy vs. bandages) might induce different types of pain, but this was beyond the scope of our study. Our study compared guidelines for adults and children, which might have affected the results. The AGREE instrument does not assess actual treatment and efficacy; this needs to be undertaken by frequent audits within the department.
5.
Conclusions
The study demonstrated variability in quality, transparency, and core content in clinical guidelines on pain management in burn patients. The most highly recommended guidelines provided clear and accurate recommendations for the nursing and medical staff on pain management in burn patients. We recommend the use of a validated appraisal tool such as the AGREE instrument to provide more consistent and evidencebased care to burn patients in the clinic, to unify guideline construction, and to enable interdepartmental comparison of treatment and outcomes.
Conflicts of interest None.
Funding None.
Acknowledgments We wish to thank Henrik Jørgensen, Department of Biochemistry at Copenhagen University Hospital Bispebjerg for statistical assistance.
references
[1] Richardson P, Mustard L. The management of pain in the burns unit. Burns 2009;35(7):921–36. [2] Meyer III WJ, Patterson DR, Jaco M, Woodson L, Thomas C. Management of pain and other discomforts in burned patients. In: Herndorn DN, editor. Total burn care. 2nd ed. Saunders; 2007. p. 797–814. [3] Patterson DR, Hofland HWC, Hoflund H, Espey K, Sharar S. Pain management. Burns 2004;30(8):A10–5. [4] Stoddard FJ, Saxe G, Ronfeldt H, Drake JE, Burns J, Edgren C, et al. Acute stress symptoms in young children with burns. J Am Acad Child Adolesc Psychiatry 2006;45(1):87–93. [5] Browne AL, Hons B, Clin M, Andrews R, Schug SA, Wood F, et al. Persistent pain outcomes and patient satisfaction with pain management after burn injury. Clin J Pain 2011;27(2):136–45. [6] Norman SB, Stein MB, Dimsdale JE, Hoyt DB. Pain in the aftermath of trauma is a risk factor for post-traumatic stress disorder. Psychol Med 2008;38(4):533–42. [7] European Association of Burns. Guidelines Committee [Internet]; 2013, Available from: http://www.euroburn.org/ 142/guidelines.html [cited 13.06.13]. [8] Cluzeau F, Burgers J, Brouwers M, Grol R, Ma¨kela¨ M, Littlejohns P, et al. Delelopment and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Heal Care 2003;12:18–23. [9] Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101.
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[10] Management of Burns and Scalds in Primary Care [Internet]. Evidence-based best practice guideline; 2007;1–115, Available from: http://www.health.govt.nz/system/files/ documents/publications/burns_summ.pdf [cited 01.03.13]. [11] Hedderich R, Ness TJ. Analgesia for trauma and burns. Crit Care Clin 1999;15(1):167–84. [12] Garcı´a Barreiro J, Rodriguez A, Cal M, Alvarez A, Martelo Villar F. Treatment of postoperative pain for burn patients with intravenous analgesia in continuous perfusion using elastomeric infusors. Burns 2005;31(1):67–71. [13] Ratcliff SL, Brown A, Rosenberg L, Rosenberg M, Robert RS, Cuervo LJ, et al. The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient. Burns 2006;32:554–62. [14] Stoddard FJ, Sheridan RL, Saxe GN, King BS, King BH, Chedekel DS, et al. Treatment of pain in acutely burned children. J Burn Care Rehabil 2002;23(2):135–56. [15] Faucher L, Furukawa K. Practice guidelines for the management of pain. J Burn Res 2006;27(5):659–68. [16] Kipping B, Rodger S, Miller K, Kimble RM. Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomized controlled trial. Burns 2012;38(5):650–7. [17] Busch M, Visser A, Eybrechts M, van Komen R, Oen I, Olff M, et al. The implementation and evaluation of therapeutic touch in burn patients: an instructive experience of conducting a scientific study within a non-academic nursing setting. Patient Educ Couns 2012;89(3):439–46. [18] Hernandez-Reif M, Field T, Largie S, Hart S, Redzepi M, Nierenberg B, et al. Childrens’ distress during burn
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7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines Hejdi Gamst-Jensen a,*, Pernille Nygaard Vedel b, Viktoria Oline Lindberg-Larsen a, Ingrid Egerod c,d a
Department of Anesthesiology, Copenhagen University Hospital, Bispebjerg, Copenhagen, Denmark Department of Orthopedic Surgery, Copenhagen University Hospital, Bispebjerg, Copenhagen, Denmark c Faculty of Health & Medical Sciences, University of Copenhagen, Denmark d Trauma Centre, Copenhagen University Hospital Rigshospitalet, Denmark b
article info
abstract
Article history:
Objective: Burn patients suffer excruciating pain due to their injuries and procedures related
Accepted 22 August 2014
to surgery, wound care, and mobilization. Acute Stress Disorder, Post-Traumatic Stress Disorder, chronic pain and depression are highly prevalent among survivors of severe burns.
Keywords:
Evidence-based pain management addresses and alleviates these complications. The aim of
AGREE instrument
our study was to compare clinical guidelines for pain management in burn patients in
Burns
selected European and non-European countries. We included pediatric guidelines due to the
Clinical guidelines
high rate of children in burn units.
Pain management
Method: The study had a comparative retrospective design using combined methodology of
Pediatrics
instrument appraisal and thematic analysis. Three investigators appraised guidelines from burn units in Denmark (DK), Sweden (SE), New Zealand (NZ), and USA using the AGREE Instrument (Appraisal of Guidelines for Research & Evaluation), version II, and identified core themes in the guidelines. Results: The overall scores expressing quality in six domains of the AGREE instrument were variable at 22% (DK), 44% (SE), 100% (NZ), and 78% (USA). The guidelines from NZ and USA were highly recommended, the Swedish was recommended, whereas the Danish was not recommended. The identified core themes were: continuous pain, procedural pain, postoperative pain, pain assessment, anxiety, and non-pharmacological interventions. Conclusion: The study demonstrated variability in quality, transparency, and core content in clinical guidelines on pain management in burn patients. The most highly recommended guidelines provided clear and accurate recommendations for the nursing and medical staff on pain management in burn patients. We recommend the use of a validated appraisal tool such as the AGREE instrument to provide more consistent and evidence-based care to burn patients in the clinic, to unify guideline construction, and to enable interdepartmental comparison of treatment and outcomes. # 2014 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: Department of Anesthesiology, Copenhagen University Hospital, Bispebjerg, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark. Tel.: +45 35313531; fax: +45 35312966. E-mail address: [email protected] (H. Gamst-Jensen). http://dx.doi.org/10.1016/j.burns.2014.08.020 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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1.
Introduction
Burn is the 11th most frequent cause of death in childhood (age 1–9 years), and yet despite of the magnitude of the problem appropriate treatment of burn related pain remains an issue [1]. The degree of the burn, the person affected, and the sensory input act as mediators of the pain perception [1]. The pain varies by the depth of the skin lesion and the inflammatory response; initially the more superficial, the more painful. Burns have been classified into three groups based on their vertical spreading [2]: First-degree burns affecting epidermis, second-degree burns involving epidermis and part of dermis, and third-degree destroying epidermis and dermis. Free nerve endings add to the pain experience and while full thickness burns are initially numb, subsequent nerve regeneration might cause neuropathic pain [1,2]. The subtypes of burn related pain are: background pain, breakthrough pain, procedural pain, and postoperative pain [3]. All stages of burns might be present in the same individual, making the pain-level difficult to assess and increasing the risk of excessive or inadequate treatment. Varying etiologies and intensity of pain demand individual and flexible pain management. The long-term risk of undertreated pain is the development of chronic pain, depression and Post Traumatic Stress Disorder (PTSD) [1]. Studies show an alarmingly high prevalence of chronic pain, Acute Stress Disorder (ASD) and depression among individuals who have suffered severe burns [4–6], rendering the issue of pain management essential in modern burn care. The European Burn Association encourages its members to develop and share clinical guidelines in order to move from a clinical practice dominated by personal experience to evidence-based and cost effective practice [7]. The aim of our study was to compare clinical guidelines for pain management in burn patients in selected European and non-European countries. We included pediatric patients due to the high rate of children in burn units.
2.
Method
2.1.
Materials and methods
The study had a comparative retrospective design triangulating instrument appraisal and thematic analysis. In 2013 we contacted seven burn units in Denmark, Sweden, New Zealand and USA to recruit material for our study. The countries were convenience sampled selected for being comparable Western countries using either English or one of the Scandinavian languages, and the departments were selected on the basis of personal knowledge and a literature search. Initial contact was made to head physicians and subsequently to nurse managers, clinical specialists and other physicians by telephone or email. We accepted clinical guidelines, protocols or pathways and chose to refer to any of these instruments by the general term of ‘guideline’ in this study. We included guidelines that (a) provided references and (b) were updated within the past five years (Fig. 1). Four clinical guidelines met the criteria and were included in the study. The clinical guidelines were appraised using to the AGREE instrument (Appraisal Guidelines for Research and Evaluation) version II [8], and subsequently we performed a thematic text analysis to describe central themes in the guidelines. The appraisal by the AGREE instrument was carried out by 3 appraisers who assessed all domains and items in every guideline. The thematic analysis was performed by the corresponding author assisted by the last author.
2.2.
Strategy of analysis (guideline appraisal)
The AGREE Instrument is an internationally developed and tested appraisal instrument for assessing the quality of clinical guidelines; also providing a methodological strategy for the development of guidelines, and informing about the type of information to be included in the guidelines [8]. Clinical guidelines should be validated both internally and externally, and should be easy to use in practice. The AGREE instrument
Fig. 1 – Flow-chart of inclusion. Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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Table 1 – The AGREE instrument. Domains 1. Scope and purpose 2. Stakeholder involvement 3. Rigor of development
4. Clarity of presentation 5. Applicability
6. Editorial independence
Overall assessment
Assessment The overall objective, population and health question is clearly described. The involvement of all relevant professional groups and target population has been sought and clearly defined. Systematic literature search with grading of evidence of the selected literature. Strength, limitations and methods for formulation the recommendations are clearly described. Explicit link between evidence and recommendation. Externally reviewed by experts and has a procedure for updating. Provides specific and unambiguous recommendations. Different treatment options are clearly presented and key recommendations are easily identifiable. Describes facilitators and barriers to application as well as tools to implementation. Resources in applying recommendations have been considered. Monitoring and audit criteria are present. Funding body has not influenced the content and competing interests of developmental groups were addressed.
3 3
Overall quality and recommendation.
2 n = 23
does not assess the clinical content, quality of evidence, or impact on patient outcome, but can be used to test and compare clinical guidelines for consistency and quality. Guideline appraisal also includes judgment about the methods used for guideline development, timing of updates, and economic and editorial independence. The AGREE instrument includes six domains and two global rating items (overall assessment) addressing 23 items to be assessed in the guideline (Table 1). The domains are: 1. Scope and purpose; 2. Stakeholder involvement; 3. Rigor of development; 4. Clarity of presentation; 5. Applicability; and 6. Editorial independence. Each item is graded on a 7-point scale and domain scores are calculated by summing up the scores of the items in a domain and by scaling the total as a percentage of the maximum possible score for that domain. It is recommended that the appraisal is conducted by 2–4 appraisers to ensure reliability and validity. Domain scores are calculated by summing up all the scores of the individual items in a domain and by scaling the total as a percentage of the maximum possible score for that domain. The scaled domain scores are calculated as ‘‘obtained score minus minimum possible score’’ divided by ‘‘maximum possible score minus minimum possible score’’. Inter-rater correlation was assessed using Cohen’s Kappa.
2.3.
Number of items
Strategy of analysis (thematic analysis)
We performed a thematic analysis of the four guidelines to identify core themes [9]. We performed vertical analysis of each guideline to identify the themes, followed by horizontal analysis of each theme across the sample. Our initial strategy was deductive coding according to themes found in the literature (preliminary template). This was followed by
8
3 4
2
inductive coding to identify emerging themes in the sample (development of a category scheme). Finally, we compared the four guidelines by recording the presence or absence of the selected core themes in the guidelines.
2.4.
Ethical considerations
The study complied with the principles of the Helsinki declaration. All participation was informed and voluntary. No patients were involved.
3.
Results
The four guidelines were selected from university hospitals with specialized burn units in Denmark (DK), Sweden (SE), New Zealand (NZ) and USA (Table 2). The Danish guideline was compiled from several sources representing the instruments used by the clinicians at the unit: a specific pathway for burn care at the unit and a general guideline for pain management at the hospital. The Swedish guideline was part of a 125-page booklet: Compendium of burns. It was stated in the introduction that the purpose of the booklet was to create order in the chaos of available options and individual needs in burn patients. The New Zealand guideline was a 114-page booklet; an evidence-based best practice guideline providing a comprehensive guide to burn care [10]. A multidisciplinary team of practitioners authored the guideline. An additional five protocols and pathways provided a hands-on approach to pain management and assessment. The American guideline was based on a textbook (Total Burn Care, chapter 64), authored by a co-author of the guideline [2]. The evidence in
Table 2 – The structure of the guidelines. Denmark Local pathway for burn care + general hospital guideline for pain
Sweden
New Zealand
USA
Compendium of burns (125 pages)
Best practice guideline (114 pages) + 5 protocols and pathways for pain
Guideline + textbook chapter (evidence-based and referenced)
Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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Table 3 – Detailed appraisal of the guidelines using the AGREE instrument. Domains 1. 2. 3. 4. 5. 6.
Scope and purpose Stakeholder involvement Rigor of development Clarity of presentation Applicability Editorial independence
Overall assessment Recommendation
Denmark
Sweden 78% 59% 13% 20% 19% 11%
87% 85% 79% 76% 63% 89%
83% 59% 63% 81% 76% 64%
22% Not recommended
44% Recommended with modifications
100% Strongly recommended
78% Strongly recommended
Appraisal using the AGREE instrument
The guidelines from Sweden, New Zealand and USA had similarly high scores in Domain 1 (Scope and purpose), respectively 78%, 87%, and 83%, whereas Denmark had only 37% (Table 3). In Domain 2 (Stakeholder involvement) we found more variation: DK (17%), SE (59%), NZ (85%) and USA (59%). Domains 3, 4, and 5 (Rigor of development, clarity of presentation, and applicability) were lower in Denmark and Sweden than NZ and USA. Domain 6 (Editorial independence) followed a similar pattern: DK (3%) and SE (11%) than NZ (89%) and USA (64%). The overall assessment demonstrated a wide span of variability: DK (22%), SE (44%), NZ (100%) and USA (78%). The guideline from New Zealand was professionally written, including a statement of editorial independence in the introduction. The American guideline was dependent on the evidence published in the accompanying textbook chapter, and editorial independence was not clearly discussed in Danish and Swedish guidelines. Inter-rater correlation was assessed using Cohen’s Kappa after grouping the outcomes into three major categories (1–3), (4–5) and (6–7); the result was moderate inter-rater correlation of 0.54, 0.57, and 0.59 respectively.
3.2.
USA
37% 17% 10% 11% 10% 3%
the guideline referred to the textbook. The guideline was used in a pediatric burn unit.
3.1.
New Zealand
Thematic analysis
After rating the guidelines according to the AGREE instrument, we conducted a thematic analysis. The following core themes were identified: continuous pain, procedural pain, postoperative pain, pain assessment, and anxiety. Another four themes were identified in the NZ and USA guidelines: itching,
procedural sedation, in-hospital physical therapy, and postoperative reconstructive surgery. We did not regard these themes as core themes to pain management, and they were not included in the Danish and Swedish guidelines. After selecting the core themes, we compared the four guidelines by recording the themes as present (+), absent ( ) or briefly mentioned (+/ ), Table 4. The degree of detail and evidence-base varied across the four guidelines. In the following, we compare the main themes in the guidelines (Table 5).
Continuous pain (background pain): The DK guideline offered no recommendations; the SE guideline recommended acetaminophen or NSAID (Non-steroid antiinflammatory drugs); the NZ guideline recommended acetaminophen, NSAID or morphine, and finally, the USA guideline recommended acetaminophen, NSAID, morphine or methadone, and included special rules for small children. Procedural pain: The DK guideline recommended analgesics or visualization (non-pharmacologic intervention), the SE guideline recommended general anesthesia for initial wound care, the NZ guideline provided handy flowcharts for the administration of morphine and nitrous oxide (Entonox), and the USA guideline recommended a variety of pharmaceuticals. Postoperative pain: All the guidelines recommended opioids for postoperative care. Anxiety: Three guidelines (SE, NZ and USA) addressed anxiety. Non-pharmacological interventions were recommended by three guidelines (DK, NZ and USA). The SE guideline recommended multidisciplinary rounds with a psychiatrist once a week.
Table 4 – Presence and absence of selected core themes.
Background pain Procedural pain Postoperative pain Pain assessment Anxiety Non-pharmacological intervention
Denmark
Sweden
New Zealand
USA
+/ +
+ +/ +/ +
+ + + + + +
+ + + + + +
+ +/
(+) Theme is present, ( ) Theme is absent, (+/ ) Theme is briefly mentioned in the guideline.
Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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Table 5 – Thematic content of the guidelines. Core content
Denmark
Sweden
New Zealand
USA Acetaminophen, NSAID, morphine, methadone. Restrictions if morphine is given to children 5 years
Continuous pain at rest
Not addressed
Acetaminophen NSAID
Acetaminophen, NSAID, morphine
Procedural pain
Analgesics as ordered
General anesthesia for initial wound care
Pain level not to exceed VAS >5
Postoperative pain
Acetaminophen, morphine, ketamine, trans-mucosal fentanyl, PCA in children >5 years
Acetaminophen, morphine, nitrous oxide, fentanyl, ketamine
Pain assessment Anxiety
Acetaminophen, NSAID, morphine, peripheral blocks, PCA in children >5 years VAS, FLACC Not addressed
Not addressed Clonidine, propofol, midazolam
Addressed Midazolam
Non-pharmacological intervention
Brief mention of visualization
Not addressed
Addressed
Wong-Baker Face scale (1–5), OPAS, VAS Lorazepam, diazepam Always add anxiolytic medicine to pain medicine when preforming wound care Addressed, several suggestions given, e.g. coping skills or hypnotherapy
NSAID: non-steroid anti-inflammatory drugs; PCA: patient controlled analgesia; NCA: nurse administered analgesia; OPAS: objective pain assessment scale; VAS: Visual Analog Scale; FLACC: Face, Legs, Activity, Crying, Consolability 0–10 scale; Wong-Baker Face scale: six images depict increasing degrees of distress.
4.
Discussion
The aim of our study was to compare clinical guidelines for pain management in burn units in selected European and non-European countries. Our main finding was the wide variability in pain management and differences in the clinical decision tools in our sample. In general, the guideline from New Zealand was the most sophisticated as it had been developed as an evidence-based guideline with associated protocols and pathways. The American guideline was less integrated, and relied on evidence from a textbook. Textbooks (background literature) are inherently less updated and evidence-based than published papers (foreground literature). The Danish and Swedish guidelines were the least comprehensive. We believe our study is the first to appraise guidelines on pain management in burn patients with the AGREE II instrument. By using the instrument we were able to compare different guidelines and describe the variation in evidencebased practice and core content. The four guidelines varied dramatically regarding management of background, procedural, and postoperative pain and anxiety. Two of the guidelines failed to comply with the standards suggested for clinical guidelines by AGREE. The thematic analysis of the guidelines served to illustrate the variability of areas addressed in burn care, whereas the assessment by the AGREE instrument addressed the variability of quality and consistency within the guidelines. Multimodal analgesia has been recommended for moderate to severe burn [11]. The principle is balancing systemic and regional medications to obtain optimal short and long-term pain relief, and the best combination of agents for posttraumatic analgesia still needs further investigation. Protocols vary on the administration of multimodal analgesia including oral analgesics (e.g. paracetamol) for low to moderate pain to intravenous opioids (e.g. morphine, tramadol, phentanyl) in
continuous perfusion or patient controlled analgesia (PCA) in severe pain, in some cases combined with benzodiazepines and hypnotics [12]. A survey has shown that optimal management of anxiety and pain reduces ASD [13], suggesting that long-term consequences of burns can be reduced. Persistent pain, depression and PTSD are highly prevalent in burn victims [5], and a study shows that in pediatric burn victims (2–48 months) there is an association between the extent of the burn, the heart rate, the pain level, and the parents’ reactions to the pain experienced by the child [4]. Another association was found between pain and ASD during the peritraumatic period (0–48 h post trauma) and the development of PTSD [6]. These studies support the need for addressing anxiety as well as pain. Several studies have shown that pain at rest and procedural pain vary in quality, intensity and duration [3]. For this reason shorter acting analgesics are recommended for wound care. More studies are suggesting non-pharmacological pain management including hypnotherapy, massage, distraction, virtual reality, and active coping [2,14], which demonstrates the need for integrating non-pharmacological solutions in clinical guidelines [15]. The guidelines from Denmark, New Zealand and USA included non-pharmacological suggestions for children, e.g. the American guideline referred to Child Life Therapy Department of Psychology for teaching and development of coping skills, and the New Zealand guideline referred to a Hospital Play Specialist Team to support the patients and caregivers during procedures. Other non-pharmacological options included therapeutic touch, cognitive enhancement, hypnotherapy, and virtual reality [2,16–18]. As suggested in a trial protocol for a virtual reality tool, there might be a link between reduced pain, stress and anxiety and improved healing time in acute burn wounds [19]. This underlines the need for incorporating non-pharmacological tools in a clinical guideline.
Please cite this article in press as: Gamst-Jensen H, et al. Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.08.020
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The Swedish, New Zealand and USA guidelines considered the long-term effect of suboptimal pain management, and the Swedish unit offered weekly multidisciplinary patient assessment, including psychologist and psychiatrists. According to the AGREE instrument ‘editorial independence’ refers to the degree of influence from the funding body on the development of the guideline [8]. Also, it indicates that the particular interests of the guideline developers have been recorded and addressed. In the Scandinavian welfare system healthcare is financed through taxes, however, in recent years the welfare system has been threatened by globalization, which means that funding has been less generous than earlier [20]. The Danish and Swedish scores in editorial independence might indicate greater editorial independence compared to other countries that depend financially on private medical insurance. Competing interests of the developers, however, might still exist. The therapeutic effect of protocolled practice is supported in the literature [13,21,22]. Factors that influence implementation of guidelines are available resources, quality assurance, and belief in benefits of guidelines [23]. A meta-analysis identified management support, learning environment, functional differentiation and local consensus as important issues in guideline implementation [24]. Guideline development does not suffice without an implementation strategy. A variety of options are available in pediatric pain management, but each department should not attempt to implement too many interventions at once. We have discussed the importance of evidence-based practice and have pointed to a number of core issues that need to be dealt with when treating burn patients (e.g. anxiety, acute pain, procedural pain, itching). The AGREE instrument provides an excellent framework for constructing and appraising evidence based guidelines; moreover the process might lead to more uniform guidelines, thus enabling interdepartmental comparison of treatment and outcomes.
4.1.
Limitations
The AGREE-instrument is tool for the development and appraisal of clinical guidelines. In using three appraisers in our study we complied with the recommendations of the AGREE instrument. We used a broad definition of a guideline including protocols, pathways and clinical guidelines, which has probably limited the comparability of the instruments and the transferability of our results. The guidelines we assessed did not recognize the clinician– patient dyad as the decision-making unit. It is important in future studies to address the degree of collaboration between patient and professionals. Our study had a unilateral focus on pain without describing the context, i.e. the strategy of burn treatment. Different treatment modalities (e.g. hydrotherapy vs. bandages) might induce different types of pain, but this was beyond the scope of our study. Our study compared guidelines for adults and children, which might have affected the results. The AGREE instrument does not assess actual treatment and efficacy; this needs to be undertaken by frequent audits within the department.
5.
Conclusions
The study demonstrated variability in quality, transparency, and core content in clinical guidelines on pain management in burn patients. The most highly recommended guidelines provided clear and accurate recommendations for the nursing and medical staff on pain management in burn patients. We recommend the use of a validated appraisal tool such as the AGREE instrument to provide more consistent and evidencebased care to burn patients in the clinic, to unify guideline construction, and to enable interdepartmental comparison of treatment and outcomes.
Conflicts of interest None.
Funding None.
Acknowledgments We wish to thank Henrik Jørgensen, Department of Biochemistry at Copenhagen University Hospital Bispebjerg for statistical assistance.
references
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