The management of pain is a public health issue. It9s a part of the institutional project of care of the University Hospital of Brest. Shoulder pain affects 15 to 70% of hemiplegic patients after stroke admitted to Physical and Rehabilitation Medicine (PRM) units. It has a negative impact on the PRM programs and on the functional results after upper limb rehabilitation. In the absence of consensus treatment, prevention outweighs support. Hemiplegic stroke patients represent 70% of recruitment of the PRM neurological unit. A program of quality enhancement of clinical practice was conducted (using the resolution of problems) in 2006. The objective was the assessment of the incidence and the improvement of the management of shoulder pain. Malfunctions in all stages of care have been identified (prevention, information, diagnosis, treatment…) and led to define different actions for improvement: Preventive measures: staff training (the training program was held in 2007), education of patients and their relatives (practical training of upper limb mobilisation, positioning, transfers, writing of a booklet of education), purchasing equipment after identification, training healthcare teams upstream services (training provided in 2007 and early 2008) and information of external speakers (disseminate the brochure of education) Assessment or risk factors: screening of the pain and risk factors at enrolment (target entry sheet for nurses), regular assessment group summary Traceability or the treatment: monitoring therapeutic actions in a computerised medical record network Coordination of care: development of a protocol ‘prevention and management of shoulder pain of hemiplegic patients’ Monitoring indicators have been defined: Care records (entry sheet for nurses, opening the specific computer file after diagnosis, initiation of a target in targeted transmission of care) Assessment of staff knowledge (knowledge level before and after training) Changing the number of patients suffering from hemiplegic shoulder pain before, during, 1 and 3 years after the program. With a number of hemiplegic relatively stable over 4 years (between 93 and 101 per year), results show: In 2005 and 2006 (before and during the process), respectively 13% and 14% of patients had shoulder pain, 66 and 57% were acquired during their stay. In 2007 a 57% reduction in the number of shoulder pain was observed (ie 8% of the total number of hemiplegic patients hospitalised in the unit) of which 26% were acquired during their stay. In 2009, 14% of patients had shoulder pain and 50% were acquired during their stay. Initially, apart from improved knowledge in particular on the importance of prevention, care coordination and formalisation of practice, this program of quality improvement has significantly reduced the number of patients suffering from shoulder pain during their stay in the PRM unit. Early detection, recorded comprehensively, enables besides an immediate management of the patient in case of positive diagnosis, detects patients at risk of developing such a pain and helps to implement a focused and rigorous preventing program. The quality improvement program was strongly oriented towards prevention through education of health care teams, patients and their relatives. Formalisation of a protocol of practice has had a positive initial impact. Training of the new care givers, screening at the admission, and monitoring protocol, were maintained. Results at 3 years are disappointing. 40% of the team of carers were renewed in 2008 and 2009. The training was focused on new staff and no action has been conducted with the entire team after the initial phase. These results suggest that education and formalisation of supporting programs requires maintain an active educational policy for the staff that evolves and is continuously sought on multiple actions. La prise en charge de la douleur est un enjeu de sante publique, elle s9inscrit dans le projet institutionnel de soins du Centre Hospitalo-Universitaire (CHU) de Brest. La douleur d9epaule affecte selon les etudes 15 a 70% des hemiplegiques apres accident vasculaire cerebral admis dans les services de Medecine Physique et de Readaptation (MPR). Elle a alors un impact negatif sur le programme de MPR du patient et sur les resultats fonctionnels du membre superieur. En l9absence de consensus therapeutique, la prevention prime sur la prise en charge. Les hemiplegiques representent 70% du recrutement du service de MPR neurologique du CHU. Une Evaluation des Pratiques Professionnelles (EPP) a ete menee (selon la methode de resolution de problemes) en 2006 avec un objectif d9analyser d9ameliorer l9incidence et la prise en charge des douleurs d9epaule. Les dysfonctionnements dans l9ensemble des etapes de la prise en charge ont ete constates (prevention, information, diagnostic, traitement…) et ont conduit a definir diverses actions d9amelioration: actions de prevention: formation du personnel (programme de formation dispense en 2007), education du patient et de ses proches (formation pratique sur les mobilisations, l9installation, les transferts, redaction d9une plaquette d9education), achat des equipements necessaires apres recensement, formation des equipes soignantes des services d9amont (programme de formation dispense en 2007 et debut 2008) et information des intervenants exterieurs (diffusion de la plaquette d9education) actions d9evaluation: depistage systematique de cette douleur et des facteurs de risque a l9admission des patients (macro-cible-entree), evaluation reguliere en groupe de synthese actions de tracabilite des traitements: suivi des actions therapeutiques dans un dossier de soin informatise en reseau action de coordination des soins: redaction d9un protocole ‘prevention et prise en charge d9une douleur d9epaule du patient hemiplegique’ Des indicateurs de suivi ont des definis: evaluation des dossiers de soins (renseignement de la macro-cible entree, ouverture du dossier informatise des le diagnostic pose, ouverture d9une cible dans les transmissions ciblees) evaluation des connaissances du personnel (niveau de connaissance avant/apres formation) evolution du nombre de patients hemiplegiques souffrant de douleurs d9epaule avant, pendant, 1 an et 3 ans apres l9EPP. Avec un nombre d9hemiplegique relativement stable sur 4 ans (entre 93 et 101 par an), l9analyse des resultats montre: en 2005 et 2006 (avant et pendant la demarche), respectivement 13% et 14% des patients ont presente une douleur d9epaule, dont 66 et 57% etaient acquises dans le service. En 2007 une reduction de 57% du nombre de douleurs d9epaule a ete observee (soit 8% du nombre total de patients hemiplegiques hospitalises) dont 26% etaient acquises durant leur sejour. En 2009, 14% de patients presentaient une douleur d9epaule dont 50% acquises dans le service. Initialement, au dela d9une amelioration des connaissances portant notamment sur l9importance de la prevention, de la coordination des soins et d9une formalisation des pratiques de soins (protocole), cette demarche d9amelioration de la qualite a permis de reduire de facon significative le nombre de patients souffrant de l9epaule durant leur sejour dans le service de MPR. Le depistage precoce, renseigne de maniere exhaustive permet, outre une prise en charge immediate du patient en cas de diagnostic positif, de depister les patients a risque de developper une telle douleur et de mettre en oeuvre de maniere ciblee et rigoureuse les moyens de prevention necessaires. Cette EPP, fortement orientee vers la prevention par l9education des equipes de soins, des patients et leur entourage et par la formalisation des pratiques dans un protocole a donc eu un impact initial positif. Les actions de formation, le depistage a l9admission et le suivi du protocole, ont ete maintenus. Les resultats a 3 ans sont decevants. 40% des equipes de soins et de reeducation ont ete renouvelees, en 2008 et 2009. La formation a ete ciblee sur le personnel nouveau et aucune action n9a ete menee avec l9ensemble de l9equipe apres la phase initiale. Ces resultats semblent montrer que l9action d9education et la formalisation des prises en charge de prevention necessitent le maintien d9une politique educative active aupres d9un personnel hospitalier qui evolue et qui est en permanence sollicite sur des actions multiples.