Gauging a patient’s pain level is a critical bedside task. Pain offers clues to the severity of an illness or injury and guides clinicians to diagnoses and treatments. Perhaps most importantly, accurate pain assessments enable effective pain management.
But the language of pain is subjective, especially among children. Without a standard way to measure pain, an assessment ultimately says very little. Four decades ago, a pair of nurses created the now ubiquitous Wong-Baker FACES® Pain Rating Scale, a validated tool to help children quantify their level of pain.
The pioneering nurses’ work exemplifies how a seemingly immeasurable characteristic can be assigned a number to guide clinical interventions. The need for this type of solution is common in children’s hospitals and vital to ongoing improvement efforts, said Aisha Furbach, CHA’s vice president of child health quality.
“Quantifying qualitative characteristics helps children’s hospitals be proactive in areas that may not rise to the level of inpatient quality indicators,” Furbach said. “These types of measurements can be vitally important to pediatric patients’ experiences with the organization.”
Clinical changes are measured by vital signs, for example, while more indefinable traits may manifest in staff and patient engagement scores or even safety outcomes. “Hospitals may see these types of things showing up as problem areas in complaints and grievances.
When you explore the patient’s feedback and general point of view, you may find concrete needs worth addressing,” Furbach said.
Identifying those needs isn’t always clear cut, given the difficulty of developing metrics for things that can’t be measured with a device or tool. Even so, children’s hospitals are finding ways to measure difficult-to-define aspects of clinical and operational processes.
Defining emotional harm
As a certified child life specialist, Barbara Romito recognizes the long-term health implications caused by emotional harm in health care.
“There is a theory that emotional harm has more of an impact on patients and their families than physical harm. They may forget that needle stick, the ouch. But they remember the emotions associated with the ouch, and that’s what they’re thinking about over and over again after hospitalization,” said Romito, director of child life and family centered care at The Bristol-Myers Squibb Children’s Hospital at Robert Wood Johnson University Hospital.
"These types of measurements can be vitally important to pediatric patients’ experiences with the organization."
To address emotional safety at the same level as physical safety, BMSCH created a way to classify emotional harm events.
First, the team educated hospital staff about emotionally safe care using a framework developed by the Association of Child Life Professionals’ Emotional Safety Initiative. “Our initial goal was to get people hearing the words ‘emotional safety’ so they could put a name to what it means to cause emotional harm,” Romito said.
Next was creating a way to measure emotional harm. “We wanted to create a system that aligned with our existing safety event classification system,” Romito said. To that end, the team created the BMSCH Emotional Harm Severity Scale, defining four levels of harm.
A rating of one represents severe emotional harm while four indicates no apparent harm. “It is a self-developed scale, but it is grounded in child development and family systems theory,” Romito said.
Previously, safety events received only a physical harm classification. In January 2022, the hospital began classifying emotional harm events as well. Physical and emotional events sometimes mirror one another, but often there’s no connection. For example, a patient did not experience physical harm due to slower-than-normal lab results, but the delay may have caused emotional harm.
Romito said staff are increasingly reporting emotional harm events without any associated physical harm. “We’re proud because people are really understanding events can potentially cause no physical harm but can have severe emotional harm.”
"There is a theory that emotional harm has more of an impact on patients and their families than physical harm."
Brandi Handel, MSN-FNP, director of children’s hospital outcomes at BMSCH, said the hospital’s safety event classification system helps identify areas for improvement. “Every month, a multidisciplinary committee made up of nursing directors, medical directors, educators, child life specialists, administrators, and pharmacy staff talk through each safety event. We come to consensus on classifying both the physical and emotional harm of these events,” Handel said.
After classification, the team considers how to address the harm. “Everyone is accountable to know what harm happened to that patient and to take care of it, whether it’s a conversation, an apology, a child life intervention, or something larger,” Romito said.
For instance, the team found that a labeling inconsistency requiring a second blood draw from patients was the root cause for an increase in moderate emotional harm reports. “We addressed the issue and significantly decreased the number of moderate emotional safety events,” Handel said.
The BMSCH Emotional Harm Severity Scale is being studied for validity. In the meantime, the hospital continues to make emotional safety a focus. “We’ve really seen it emerge as a value for BMSCH,” Romito said. “Everyone owns physical safety. Everyone owns emotional safety. That’s the care we expect for our patients and families.”
Productivity targets for music therapy
No two days look the same for music therapists at children’s hospitals. The modality encompasses much more than playing music in a patient’s room, which makes it difficult to create productivity targets.
During any given week, a therapist may play music to calm an anxious child or comfort a drug-exposed newborn. They may spend hours writing a song for the family of a patient in hospice care or incorporating the heartbeat of a child having an organ transplant into a song. The neurology team can utilize music therapy treatments to induce brain plasticity, resulting in cognitive, motor, speech, language, and sensory improvements following a neurologic injury; others may use music to help children develop gross motor skills.
Despite the diversity of tasks, leaders of the music therapy department at Kentucky Children’s Hospital sought to create a productivity target for the team. “We suspected we should be touching more patients and needed a way to gauge productivity,” said Kelsey Rahenkamp, a clinical administrator who assumed leadership of the department in 2023.
Identifying a target required research and observation.
“It was really complex trying to figure out the level of work involved, especially since there’s a good deal behind the scenes that supports hands-on patient interactions,” said Amanda Biddle, practice manager.
"We had to balance being sensitive to the team’s needs while pushing for progress."
Biddle and Rahenkamp started by looking at benchmarks for modalities like physical and occupational therapy. The pair also looked to a workforce analysis created by the American Music Therapist Association and had one-on-one conversations with music therapists to better understand their work.
“We did a pretty extensive time study where someone shadowed therapists for full shifts. They tracked their time in the room and average session length and identified the things that might require time outside of time with patients,” Biddle said.
That information laid the groundwork for a target. Tracking the productivity measures was another matter. The team initially used a simple Excel file but went on a “lengthy journey” to find a way to pull some tracking information from the Epic EHR. Music therapists track individual, group, and attempted sessions, each with different weights. Administrators pull each therapist’s totals from Epic and calculate a weighted number. Unblinded scores are shared with the team.
Managing the change in expectations was difficult, but worthwhile. “There were some really tough conversations, and we had to balance being sensitive to the team’s needs while pushing for progress,” Rahenkamp said. “Six months later, the data has shown we have a bigger impact on our patients with the same number of FTEs, and therapists recognize they have more autonomy in their schedules.”
Having a productivity target in place also supports growth plans as demand for music therapy continues to grow at the hospital. “Music therapy is still a somewhat new modality to our country, and I think in five to 10 years, it will look incredibly different. It’s going to be a lot more common, and departments are going to be a lot larger,” Rahenkamp said. “Our hope is this can move our country just one step in the right direction to help us get there.”
Describing symptoms on all skin tones
Many health care educational materials use “pink” to describe signs of diaper rash, “blue” for cyanosis, and “red” for erythema. Though exact, these colors only describe how the conditions appear on white skin. Symptoms may look or feel different on other skin tones.
Without precise descriptions of symptoms on brown or black skin, providers could miss subtle changes. For example, darker skin may mask redness and blanching, both indicators of early-stage pressure injuries.
A nursing-led initiative at Seattle Children’s sought to describe how skin symptoms look on patients of varying skin tones instead of making broad generalizations. “We wanted people to know that simply using race or ethnicity as an assumption of somebody’s skin tone wasn’t the most inclusive way to go about it,” said Mari Moore, MSN, RN, NPD-BC, RNC-NIC, manager of nursing professional development.
An interdisciplinary group worked to describe specific symptoms on all skin tones. Over 18 months, the group collaborated with a dermatologist, consulted the hospital’s Family Advisory Committee, and conducted a literature review. The results were a job aid for inclusive language for skin symptoms and updates to the clinical documentation function.
“We wanted to be as descriptive as possible, using evidence-based ways to assess skin that take into account people with differing skin tones,” Moore said. “We didn’t want to provide a long list of dos and don’ts but instead give some high-level guidelines while being very objective.”
"We wanted people to know that simply using race or ethnicity as an assumption of somebody’s skin tone wasn’t the most inclusive way to go about it."
Seattle Children’s inclusive-language job aid offers condition-specific examples. For cyanosis, the aid instructs nurses to look for a blue or gray tinge on the lips, tongue, and gums — areas where the condition may be easier to identify on patients of all skin tones. For jaundice, the guide states yellowing may be subtle on the skin but more obvious on the sclera of the eye.
When assessing skin, the guide calls for nurses to:
- Perform bilateral examinations to compare skin tone across the body.
- Use touch to identify temperature, feel textural differences, observe skin response to pressure, and examine tissue consistency.
- Prioritize symptoms that affect everyone equally, such as how it looks when compared to the patient’s regular skin or how the patient reports it feels (e.g. itchy, warm, dry).
- Ask the patient’s family or caregiver about skin changes.
Along with the job aid, the hospital’s EMR now offers more ways to describe skin tone. Pink was removed as the default option for “normal skin” and more color descriptors were added. Instead of “appropriate for ethnicity” as a skin color choice, the EMR now includes “appropriate for usual tone.”
Moving forward, Seattle Children’s will continue to incorporate inclusive language around skin tone into day-to-day work. Many staff members have requested a photo library showing how dermatological conditions appear on various skin tones. That project is on the hospital’s long-range plan; in the interim, staff use the Skin Deep Project, an open-access photo bank of skin conditions.
“Our organization prioritizes this work because we know it’s important to people who work here, and we know it’s important to patients and families,” Moore said.
