Francophone Hub: Expanding our approaches to pain management with Tout doux

SKIP’s Francophone Hub, hosted at CHU Sainte-Justine, is helping families and health professionals reduce procedural pain and distress with the Tout doux institutional project. Tout doux is a multi-disciplinary, comprehensive approach to procedural pain management that has become a core initiative of the hospital and is gaining the attention of other institutions in Canada.

CHU Sainte-Justine may be new to SKIP as the host of our Francophone Hub, but children’s pain management has been the Hub Leads’ priority for more than 10 years. Many health professionals, like Dr. Edith Villeneuve and her team, first made children’s pain a focus within the hospital before eventually passing the baton to practitioners including SKIP Hub Leads: Dr. Marie-Joelle Doré-Bergeron and Dr. Evelyne D.Trottier. Over the past years, pain management has become a top priority for their institution. The development of an institutional policy on procedural pain and distress prevention and management formalized the hospital’s commitment to reducing pain for all children and youth. As they continued exploring new, multi-disciplinary approaches to procedural pain management, their work grew to become a hospital-wide pain management initiative at CHU Sainte-Justine, called Tout doux: Pour des soins tout en douceur, operating with a team of more than 15 people, with a medical (Drs. Doré-Bergeron and D. Trottier) and nursing (Mrs Annie Lacroix) co-direction. The main objective of the Tout doux project is to help families and health professionals across the hospital reduce procedural pain and distress. Tout doux’s collaborative team of people working towards addressing children’s procedural pain includes doctors, nurses, patient partners, child life specialist and special needs educator, communication advisors, administrators and more. Thanks to their collaboration with SKIP, this model is gaining attention among other health institutions across the network.

The Tout doux initiative uses a multi-disciplinary and comprehensive approach to procedural pain management that covers the four P’s: prevention, as well as psychological, physical, and pharmacological approaches to pain. “With Tout doux, we try to focus on the combination of the 4P’s and not just on pharmacology. It needs to come in a full package. When combined, these strategies are more effective than just one strategy alone”, says Dr. Evelyne Trottier.

Tout doux has provided tools and training to help physicians consider other, less painful treatment options when possible. As the project deploys throughout each of the hospital’s sectors, the team conducts audits to capture the impact of the project’s deployment, gives mandatory training on the 4P approaches to all caregiving staff, and provides field support. One strategy Tout doux encourages is to reflect on the necessity of doing multiple procedures or blood tests before ordering them, trying to limit pain and distress for patients.

Strong institutional support has been instrumental in the success of the initiative. “Many people were interested in making a change in treating pain, but often didn’t have the right resources and tools on a daily basis to implement that change,” says Sarah Loemba, SKIP Knowledge Broker for the Francophone Hub. “Now, with the support of Tout doux and SKIP we are closing the gap in the existent disparity between the production of research and field application. Health professionals and families now feel more equipped to confidently advocate for and implement the 4P’s approaches to manage pain. And it makes a big difference for the care of children. It has especially given hope and support during the chaos of COVID-19.”

“Making a difference for kids is what matters most,” adds Dr. Marie-Joelle Doré-Bergeron. “Improving experiences with pain can change the way children think about procedures, needles, and healthcare in their future.” Children and families have played a central role in the development of Tout doux and its tools and training. “They are the ones receiving the treatment, and so it is important that they actively are included in the decisions of the methods of treatments they will receive.” Patient partners are central to every aspect of work Tout doux engages in.

Marie-France Langlet, Parent Partner and Senior Advisor leading the Patients, Families and Health Professionals Office at CHU Sainte-Justine, could not agree more. “Patients and their families are first to experience the impacts of appropriate pain management and know the related anxiety, hence the importance of including some patient and parent partners in the entire process of co-creating improved care. Partnering, collaborating with families is one of the four core values of the CHU Sainte-Justine, so it is natural to have families on board since the very beginning of Tout Doux.”

“By providing health professionals and families with appropriate tools and techniques to reduce pain and related anxiety, Tout Doux has an immediate positive impact on the quality of patient care: children suffer less during procedures, they feel better and, consequently, so do their parents. As a parent now, we know of numbing creams, better positioning, we know about the benefits of distraction, and we can take this information wherever we go. Instead of saying empty things like ‘Don’t worry, it won’t hurt’ or ‘If you don’t cry, I will give you a reward,’ we can say ‘look at me’ and ‘let’s watch this video.’ Concrete tools to better contribute to the experience and manage the pain and anxiety. If my kid has a vaccine somewhere else, because I got these tools from Tout doux, I can help make that experience better, no matter where we are.”

“It has a strong positive impact on the relationship between practitioners and families, improving trust and partnership between them in the day-to-day care environment and, moreover, enables a healthier relationship between parents and children needing treatments. Parents can be more honest in general about care treatments. Toux doux’s approach not only helps children now but will have positive impacts on children’s lives as they grow up.” Mrs. Langlet’s own 28 years old son was treated in the Oncology Department of the CHU Sainte-Justine for leukemia when he was a child. He had to undergo many painful procedures and she can still remember herself saying these platitudes, to reassure him but also sooth herself. “It is so powerful to be part of changing the treatment of pain for this generation of children. It is healing to work with Toux doux and SKIP’s Francophone Hub to advocate for and support families going through the same things my family went through.”

The team continues to nurture relationships and strengthen connections with other regional health institutions too, sharing expertise on both SKIP and Tout doux to promote institutional change in pain management practices. Toux doux has presented their model and strategies to centres across Quebec and even international conferences (like the Réseau mère-enfant de la francophonie in France and the Secrétariat international des infirmières et infirmiers de l’espace francophone in Ottawa), expanding the use of evidence-based methods for managing procedural pain, and sharing their recommendations, knowing there is no one-size-fits-all. This is part of the SKIP lens, bringing a national network of experience to local practices. These include simple, yet innovative distraction strategies like replacing the beige ceiling tiles of procedural rooms with ceiling tiles painted with engaging images, inspired by a patient’s feedback, and installing TVs in ER and patient rooms to occupy patients’ attention. Their approach to this work is based in a perspective of learning and collaboration, readily sharing the guidelines they develop on procedural pain, and supporting the implementation of them with organizations, a core ethos of SKIP.

“In partnership with SKIP, the Francophone Hub has been able to extend the reach and impact of tools and resources they develop at CHU Sainte-Justine,” said Sarah. “Making these resources available to Francophone centres is so valuable! Our hub is also addressing pain management on several levels including our working group on sickle cell disease. There are so many ways we are working within CHU Sainte-Justine and beyond to improve pain management for children and carry on the important work that began here more that 10 years ago.”

With the support of SKIP’s Francophone hub, the local impacts of Tout doux are expanding far beyond the hospital thanks to the network’s national perspective.