Assessing the Usability, Feasibility, and Acceptability of the Hauer-Houtrow Algorithm for Diagnosing Pain in Children with Severe Neurological Impairment

Purpose: The purpose of this quality improvement project was to assess the usability, feasibility, and acceptability of the Hauer-Houtrow Algorithm in a specialty clinic for children with special healthcare needs. Background: Children with severe neurological impairment (SNI) have a significant reduction in physical, cognitive, and communicative abilities stemming from a physiologic process affecting the central nervous system. These children experience pain from a variety of sources including medical devices and procedures, the disease process, activities of daily living, and potentially life-threatening complications of their disease. Pain behaviors vary widely between patients making accurate assessment difficult and can lead to underrecognized pain, misdiagnosis, and potentially fatal complications. Numerous studies address the assessment of pain in children with SNI, yet few studies research how to diagnose the source of pain in this patient population. The child's ineffective communication makes it difficult to diagnose the source of their pain, necessitating a specialized tool such as the Hauer-Houtrow Algorithm. Methods: This quality improvement project was conducted using a four-step process. The first step involved conducting a survey to evaluate providers' initial thoughts on the overall algorithm. The second step included an education component to teach providers how to use the algorithm. In the third step, the algorithm was implemented in the specialty clinic with the four providers over a period of three months. Lastly, a final survey was used to evaluate the providers' final thoughts and opinions on using the algorithm in clinical practice. An opportunity to provide written feedback on the algorithm was also provided. Outcome: Results from the first survey showed that all providers agreed (25%) or strongly agreed (75%) that the clinical pathway presented in the algorithm was applicable to children with SNI. During the implantation phase, the algorithm was used for 19 patient scenarios and helped avoid escalation of care in six of those encounters. The final survey's results showed that although the algorithm did not always help the provider's personal clinical practice due to being experts in this field, it could potentially improve the care of children with special healthcare needs in other settings such as primary care offices, urgent care, or emergency rooms. Conclusions: This project demonstrated that providers with expertise in children with special healthcare needs consider the Hauer-Houtrow algorithm to be well written, easy to use, and potentially beneficial for providers with less expertise in this patient population. The project supports the use of the Hauer-Houtrow Algorithm in clinics and hospitals to facilitate the accurate diagnosis and treatment of pain in children with SNI who cannot communicate. Additionally, it is recommended that further research take place in pediatric clinics, emergency departments, and urgent care facilities to determine whether or not the Hauer-Houtrow Algorithm could improve the diagnosis of the source of pain in this special patient population.