The Use of the TyMed™ Wheel in Postoperative Pediatric Pain Management at Home

Monday, 9 November 2015

Celeste Rene Knoff, MAN, MBA, BS, RN, CRRN
Rehabilitation Department, Gillette Children's Specialty Healthcare, St Paul, MN, USA

The treatment of postoperative pediatric pain has historically been suboptimal (Avansino, Peters, Stockfish, & Walco, 2013; MacLaren Chorney, Twycross, Mifflin, & Archibald, 2014; Rony, Fortier, Chorney, Perret, & Kain, 2010; Sutters et al., 2012; Vadivelu, Mitra, & Narayan, 2010).  Reasons for this deficiency are many and include personal biases of clinicians and parents, inconsistencies and difficulties in pain assessments, obstacles to educating caregivers on pain management, and a lack of research on best practices for pediatric pain management.  Reduced hospital stays and increased outpatient procedures are shifting the onus of pain management for children to their primary caregiver, usually a parent.            

            Teaching parents how to provide safe and effective pain management is a priority in the care of postoperative children at home (MacLaren Chorney, 2014), especially after complex orthopedic surgeries.  The protocol for pain management after these surgeries includes opioids and benzodiazepines and the potential for underuse, misuse, and adverse drug events presents a particular challenge for parents and potential safety issues for children. Educating parents in the safe, effective use of pain medications, the reduction of medication side effects, and the appropriate tapering of the medications is paramount.  This education is complex and multifaceted. Best practices for patient education have yet to be refined and the needs of this group of learners are extensive (MacLaren Chorney, 2014).

              It is not enough to teach on just the cognitive level.  Psychosocial, cultural, and environmental factors impact both the learning and the perceived need for managing children’s postoperative pain management at home.  Educating caregivers on this important task requires a learning device that addresses these barriers and provides a simple guide for medication management.  Such a learning device was created and designed for the purpose of assisting parents in the timing, the dosing, and, ultimately, the elimination of opioid and antispasmodic medications for their children at home.  This tool is called the TyMed ™ Wheel.

            The TyMed ™ Wheel is a simple device that looks like the face of a 24-hour clock.  There are four, moveable, colored arrows on the device that represent 4, 5, 6 and 8 hour increments.  Using the TyMed ™ Wheel, parents time the next dose of their child’s pain medication.  As they continue around the wheel, they can also plan subsequent doses of the medications for 24 hours.  Using the accompanying medication worksheet, parents record the times of medication administrations, pain assessments, and any significant side effects.  This record assists parents in creating a tangible, visible plan for daily management of the child’s pain. It also helps minimize potential problems such as overmedication, duplicate dosing, missed doses, and overlooked side effects.

            The TyMed ™ Wheel was developed and evaluated over a three-year period during two pilot studies.  Both studies were reviewed by an Institutional Review Board and deemed exempt.  The first study focused on tool design and usability, using input from 13 nurses and 18 parents.  All nurses and parents completed an interview after a demonstration of the TyMed ™ Wheel. All participants expressed an understanding of the wheel and over 90% of the parents indicated an expectation of its use at home.  Both groups provided insight that added clarity to the design and use of the wheel and the medication worksheet.           

            The second study evaluated parental understanding and subsequent home use of the TyMed ™ Wheel.  The target population was children who had undergone a complicated orthopedic surgical procedure and were discharged on a complex pain management protocol that consisted of four oral medications: oxycodone (every 4 hours), valium (every 4 to 6 hours), Tylenol (every 4 hours but not more than 5 doses in 24 hours), and vistaril (every 6 hours).  All inpatient orthopedic nurses were instructed on the use of the wheel by demonstration and received a written guide.  These inpatient nurses taught 25 families how to use of the TyMed ™ Wheel prior to discharge.  Families were given the wheel and ten medication worksheets for home management of their child’s prescribed pain medications.   Parental understanding of the TyMed ™ Wheel was evaluated using a ten question written survey completed by parents after the discharge teaching by the inpatient nurse.  Parental use of the wheel at home was evaluated using a structured follow-up call to each family 14-21 days post-discharge. 

            Most families (n=23) completed the ten question parental understanding survey.  These families indicated a quick understanding of the purpose and use of the wheel.  Most expected to use the wheel at home and anticipated it would be useful.  Eighteen families completed the post-discharge follow-up call.  These families showed some mixed responses.  While some families used the wheel in conjunction with the medication worksheet, many preferred to use only the wheel or the worksheet.  Regardless of the tool used, the majority of families indicated that by using one or both of the tools, their child had good pain management and none identified any significant side effects.  The majority of respondents planned to keep their wheels and use them for other types of pharmacological administration. 

            Inadequate treatment of pain contributes to higher rates of complications, lower quality of life, and has significant financial consequences for individuals and society (Zhang et al., 2008). A study conducted by Rony et al. (2010) reported that parents gave subtherapeutic analgesic doses 70% of the time at home and 58.8% of the children received less than the recommended daily dose of pain medication.  Because this problem is so pervasive, it must be addressed.  Pain can lead to multiple physical and psychological complications.  The TyMed ™ Wheel was created to provide parents with a tool to maximize the safe administration of complex pain protocols while minimizing pain medication side effects and complications. This tool can be particularly useful when there are multiple caregivers such as two parents or grandparents.  Once a plan is established for the day, all caregivers can easily follow it.  The TyMed ™ Wheel can also be useful when increasing the times between doses as patients begin to taper off their medications.  By using a different colored arrow for the next dose timing, parents are reminded to decrease their child’s medication once their child’s symptoms warrant it.

            Our findings suggest that the TyMed ™ Wheel effectively assists parents in providing optimal, safe pain medication management at home.  Full implementation of the TyMed ™ Wheel in the inpatient and same day surgery departments is planned for 2015.