How can we do this better?

Health care professionals – nurses, doctors, physical therapists and so on – go into their professions because they want to help people. Sometimes, however, these people find themselves in situations where, even when they are using the best available treatments, they find themselves wondering if the treatment could be done better. 

One way of answering this question is to review the available research evidence related to a particular treatment or condition. The Cochrane Collaboration has been set up to produce systematic reviews of research evidence in order to answer questions about what treatments work best. Sometimes doing this type of review will show that we don’t know enough about a treatment – in other words, more research needs to be done. Other times, it may show that there is reason to use a different treatment. 

Reviewing all the available research about a treatment can be a huge task. In some cases, there are many studies, sometimes with conclusions that contradict each other. In those situations, it can be very difficult for a health care professional to know what to conclude. However, a systematic review can help provide clarity about which treatment option is best.

In other cases, a review establishes that very little research has been done. This can encourage researchers to investigate further. This was the case for Denise Harrison, a nurse researcher in Ottawa, Ontario. Her account, which was written for the Canadian Cochrane Centre’s recent competition for stories about the impact of Cochrane reviews, follows.

How can we do this better

Source: Canadian Cochrane Centre

Helping a physician inserting an intravenous line in a tiny baby boy with chronic lung disease is where it all began. The painful procedure was just one of hundreds the baby had endured – all, or at least the large majority, performed with no pain relief. The baby cried weakly, began gasping, turned blue, then white, then grey, and as we watched his heart rate on his ECG monitor plummet down to the 40s, we stopped the procedure so we could perform resuscitation.

A key problem was the baby still had no intravenous line, so we had to start the procedure all over again. Although I had been responsible for performing probably thousands of painful procedures with no pain management on sick, hospitalized infants, this case especially caused me grief, angst, guilt and regret. My question to the physician was, “How can we do this better?”

The year was 1999. I turned to the published literature, and found a Cochrane Systematic Review of sucrose for neonatal procedural pain management (Stevens and Ohlsson, 1998). This review, the first systematic review I had ever read, included 10 RCTs (randomized controlled trials), and demonstrated that sucrose reduced pain during heel lance and venipuncture. From this point on, I could no longer do nothing to reduce sick babies’ pain.

The results of the sucrose systematic review could not simply be extrapolated to the population of sick infants in the NICU (neonatal intensive care unit) I worked in, as all infants had undergone surgery, had a history of opioid exposure, and many had congenital abnormalities. Infants with this history were excluded from all previous RCTs included in the systematic review; therefore I went on to conduct the first RCT of sucrose in infants with surgical and opioid exposure. The results were similar to the ever-growing number of other RCTs – that sucrose reduced behavioural responses during heel lance or venipuncture.

The Cochrane Systematic Review of sucrose for neonatal pain has continued to be updated, and is now one of the largest neonatal systematic reviews, including 57 trials and almost 5000 infants. However, this review only included sucrose, despite many studies evaluating the analgesic effects of other sweet solutions, especially glucose. In collaboration with the same authors of the sucrose review, and a PhD student from Brazil, we conducted a parallel systematic review of glucose for pain management for neonates. In this review, we included 38 trials with nearly 4000 neonates and concluded the same results – that glucose consistently reduced behavioural responses to procedural pain.

Then a key knowledge gap was the effectiveness of sucrose or glucose in older infants up to one year of age, then even older – in children up to 16 years. Cochrane Systematic Reviews have now been published to address sweet taste analgesia in these populations (infants up to 1 year, children 1-16 years). Today, in total, there are over 200 individual RCTs of sweet solutions for pain management in infants and one of my roles now is to try to stop the tide of placebo controlled trials of sucrose or glucose in infants. The world has the evidence. Further placebo controlled trials, especially in the neonatal population, do not tell us more. We now need to look at Cochrane for reviews informing us on best strategies to put evidence into practice; translate knowledge into action.

That first little question asked 15 years ago, “How can we do this better?”, and reviewing one Cochrane Systematic Review of just 10 RCTs, has led me down a research career path I had never intended to take and to the other side of the world to where it all started. I am happy I have helped answer my first question. We can do painful procedures better for sick or healthy, term or preterm infants by using sucrose or glucose or other effective pain management strategies based on Cochrane Systematic Reviews, namely breastfeeding (Shah et al., 2012) or skin-to-skin contact (Johnston et al., 2013). We need to continue asking the “How can we do this better?” questions, and look for Cochrane for answers – you may not only significantly improve your patients/clients outcomes, you may end up in a career you may never have dreamed about.