Commitment to Comfort Program | Quality and Safety

Boston Children's Hospital recognizes the improvement of pain management as a high priority aspect of patient care.

  • Timely and effective pain management is important emotionally, ethically (i.e. to decrease suffering) and, physically (i.e. to improve sleep, healing, respiratory function). Unfortunately, pain is not always easily managed.
  • Pain is a complex, dynamic experience influenced by many factors (including the pain stimulus, medical condition, genetics, past experiences, learned expressions, physical activity, developmental level, anxiety and stress).
  • Analgesics, especially opioids, have side effects that may limit use in patients with certain risk factors (i.e. age <6 months, obesity, respiratory compromise). Even patients without risk factors can experience serious side effects with increasing doses of opioids. Therefore, careful consideration of the mechanism of pain and the risks and benefits of analgesics is required.
  • The first step in pain management is assessment. Pain assessment is an iterative process that utilizes various observations and methodologies to approximate a person’s experience of pain (including self-reported pain intensity; behavioral measurements of intensity, vital signs, response to analgesics and other interventions and the above mentioned factors).

Pain Graph

All documented pain scores are extracted from the electronic medical record to show pain prevalence as percentages of:

  • no pain (0) 
  • mild (1-3) pain 
  • moderate (4-6) pain 
  • severe (7-10) pain scores

Safe Opioid Prescribing

Opioid analgesics have clear benefits for patients with severe pain due to cancer, sickle cell disease, surgery and critical illness. However, opioids generate risks and adverse symptoms for hospitalized children, as well as a major public health concern due to increasing frequency of deaths due to addiction and overdose. Members of our program have led hospital-wide efforts to make opioid prescribing safer for inpatients and outpatients. This effort has included:

a. Development of updated hospital-wide policies on chronic opioid prescribing

b. Electronic tracking of all opioid prescriptions to identify patterns associated with multiple prescriptions and potential concerns

c. System-wide process to eliminate codeine prescribing

d. Innovative unit dose formulations to reduce medication errors and

e. Pathways for procedure specific prescribing to foster appropriate numbers of doses prescribed for outpatients.

f. Following a multicenter trial for protocol-driven sedation and analgesia for children undergoing mechanical ventilation during intensive care (Curley et al JAMA 2015), a hospital wide process led to practice changes around weaning of infants and children from opioids and benzodiazepines. Accelerated weaning has been shown to be safe and well tolerated. Interim review indicates that this protocol has been associated with shorter duration of exposure to opioids and sedatives, with resultant reductions in hospital stay and costs.