Clinical Practice Guideline for the Management of Vaccination Pain across the Lifespan

My name is Meghan McMurtry and I am a member and evidence lead of the Help Eliminate Pain in Kids and Adults (HELPinKids&Adults) Team. Recently, a clinical practice guideline (CPG) for the management of vaccination pain across the lifespan created by the HELPinKids&Adults Team was published in the Canadian Medical Association Journal (CMAJ). The CPG contains 49 evidence-based recommendations organized into “5 P’s” of pain management:

1. Pharmacological (e.g. topical anesthetic)
2. Physical (e.g. upright positioning)
3. Procedural (e.g. no aspiration)
4. Psychological (e.g. distraction); and
5. Process (e.g. education).

The purpose of this blog is to briefly explore “all things CPG” and use our work as a thematic example.

As the name suggests, the purpose of a CPG is to guide clinical practice. Given the large research-to-knowledge gap (aka practice care gap) in many areas of healthcare, CPGs are incredibly important. In our case, while there has been a proliferation of research on the management of procedural pain in children, sadly, it is only put into practice about 5% of the time. We need to do better. Enter Anna Taddio in 2008 when she began the HELPinKids&Adults journey. The team may have shifted and expanded over time but the goal is the same: to change the face of vaccination to one without pain. In submitting our 2013 grant (Taddio, McMurtry co-principal investigators) to the Canadian Institutes of Health Research, our vision was to update and expand the 2010 guideline to include vaccination pain management across the lifespan and also provide guidance on the management of high levels of needle fear (forthcoming).

A strong CPG needs to tell a clinician what to do and how to do it. Sounds simple right? Wrong. Many researchers are used to writing and translating knowledge to other researchers and scientists in a way that will drive the research field forward. This is an important goal. However, the audience, content, as well as manner of communication differ in a CPG from typical empirical research. Although a CPG is based on a systematic review or overview of the literature, it has to go beyond the literature in order to be useful in directing an individual clinician’s behaviour. In our case, the HELPinKids&Adults Team guideline panel is a group of over twenty carefully selected experts from across Canada that were tasked with interpreting the evidence from a series of systematic reviews (seven! – see the special issue of Clinical Journal of Pain published in October 2015 which contains our overarching papers and the systematic reviews) and considering the benefits/harms, level of evidence, and cost, as guided by preferences/values. For example, we chose to prioritise the perspective of the individual being vaccinated rather than another viewpoint (e.g., policy makers). Given the sheer number of experts who may be involved, I’ll forgive you if you think that getting through this process might be a little bit like herding cats. Two important points:

1. A fearless and energetic leader (Anna) is a must and
2. Selection of highly talented individuals who are passionate about the issue and used to team-based approaches facilitates the process immensely.

One particularly challenging part of writing a CPG is that you need to avoid the “I don’t know” approach. Particularly within the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach which we used, you have to make a recommendation one way or another. As a researcher, there were times when I was tempted to say “but I don’t know!”. The bottom line though is that doesn’t help the clinician in the real world who has to do something. Can you imagine if you went to someone for help and he/she said “I can’t do anything. The field of research really isn’t clear on this issue. Come back in 10 years”. Although a CPG can certainly point to issues on which future research is sorely needed, it must provide recommendations on the best evidence available. In sum, a CPG has to provide guidance that is both explicit and practical. In addition to concrete implementation considerations, accompanying a CPG should be a series of tools that help reach this goal. For example, we included a series of 4 treatment algorithms organised by age of the person being vaccinated, a documentation tool, and copies of assessment tools. This helps close the knowledge-to-practice gap: here’s what we know, here’s what you should do, and here’s how to do it!

On a more personal note, I would like to take a moment to reflect on my journey from being peripherally involved with the 2010 guideline – I contributed to the psychological strategies systematic review in 2009 as a PhD student of Christine Chambers. Currently, as an early career researcher with a lab of my own, my roles on HELPinKids&Adults (co-PI on grant; evidence lead; knowledge translation panel, guideline panel) have continued to be immensely rewarding. Over the past three years, from our initial conversations about the grant through to the present day, I have learned an incredible amount from Anna, the other evidence leads, and the guideline panel. Having an opportunity to contribute to a body of work that is having a global impact (the World Health Organisation used our guideline as in formulating their global recommendations) is extraordinary and I am very grateful.

C. Meghan McMurtry completed her Ph.D. in Clinical Psychology at Dalhousie University in Halifax, NS and her psychology residency at Brown University in Providence, RI in 2010. She is an Assistant Professor in the CPA-accredited Clinical Psychology program at the University of Guelph, director of the Pediatric Pain, Health, and Communication Lab, and a Clinical Psychologist with the Pediatric Chronic Pain Program at McMaster Children’s Hospital. She is an Adjunct Research Professor in Paediatrics at Western University and an Associate Scientist at the Children’s Health Research Institute. Dr. McMurtry’s research and clinical interests in child health psychology focus on acute and chronic pain, medical procedure-related fear, as well as communication and family influences in these contexts. Her research has been funded by the Canadian Institutes of Health Research, the Canadian Foundation for Innovation, Team for Research with Adolescents and Children in Palliation and Grief, and the Nova Scotia Health Research Foundation. She is an evidence lead on the Help Eliminate Pain in Kids&Adults Team which recently completed a knowledge synthesis on vaccination pain across the lifespan and fear in individuals with high levels of needle fear.

The recent work of HELPinKids&Adults is supported by a knowledge synthesis grant from the Canadian Institutes of Health Research (KRS 132031); funding for open access publications was provided by The Mayday Fund.

Further reference: Immunize Canada website (for parents): http://immunize.ca/en/parents/pain.aspx