Improving pain management of abdominal pain in children presenting to the paediatric emergency department: a pre-post interventional study

Gender-based differences in assessment and management of acute abdominal pain in the emergency department: A retrospective audit

BACKGROUND

Previous research has identified gender-based differences in acute pain management in the emergency department [ED]. The aim of this study was to compare pharmacological management of acute abdominal pain in the ED by gender.

METHODS

A retrospective chart audit was conducted at one private metropolitan ED including adult patients (18-80 years) who presented with acute abdominal pain in 2019. Exclusion criteria included: pregnancy, repeat presentation within the study period, pain-free at initial medical review or documented refusal of analgesia, and oligo-analgesia. Comparisons by gender included: (1) analgesia type and (2) time to analgesia. Bivariate analysis was undertaken using SPSS.

RESULTS

There were 192 participants: 61 (31.6 %) men and 131 (67.9 %) women. Men were more likely to get combined opioid and non-opioid medication as first line analgesia (men: 26.2 % n = 16; women: 14.5 % n = 19, p = .049). Median time from ED presentation to analgesia was 80 min for men (IQR: 60) versus 94 min for women (IQR: 58), (p = .119). Women (25.2 % n = 33) were more likely to receive their first analgesic after 90 min from ED presentation compared to men versus men (11.5 %, n = 7 p = .029). In addition, women waited longer before receiving second analgesia (women: 94, men: 30 min, p = .032).

CONCLUSION

Findings confirm there are differences in pharmacological management of acute abdominal pain in the ED. Larger studies are required to further explore differences observed in this study.

Assessing Nurses' Knowledge and Attitudes towards Cancer Pain Management in Oman

Cancer care in the Gulf Cooperation Countries, including Oman, faces challenges due to increasing incidence and late-stage diagnoses. Cancer patients at later stages suffer complex symptoms, pain being a prominent one. Access to adequate pain relief is a global problem, including in the Middle East, where palliative care is lacking. Nurses play a crucial role in pain assessment and management but often lack the necessary training, resulting in inadequate relief and prolonged hospital stays. This study aims to examine the knowledge and attitudes of nurses in a national cancer center toward the management of cancer pain, with the goal of identifying any gaps in their knowledge. This is a cross-sectional descriptive study conducted among nurses at the national cancer center in the Royal Hospital. The Nurses' Knowledge and Attitudes Survey Regarding Pain (NKASRP) was used to determine the pain-related knowledge and attitudes of the nurses. Out of 150 registered nurses, 118 participated in this study (78% response rate). The mean NKASRP score was 49.6%. Half of the participants (50%) had a poor level of knowledge and attitude, 46% had fair knowledge and attitude, and only five participants (4%) had a good level of knowledge and attitude. A statistically significant association existed between knowledge and education level, years of experience caring for cancer patients, and prior pain management training (p < 0.05). A low level of knowledge and attitude among nurses in cancer pain management is a significant challenge in providing comprehensive cancer care. Adequate training of nurses in cancer pain management is essential to providing effective pain management and improving the quality of life of cancer patients.

A prospective study to compare serial changes in pain scores for patients with and without a history of frequent ED utilization

Background

In the face of the opiate addiction epidemic, there is a paucity of research that evaluates limitations for our current pain rating methodologies for patient populations at risk for drug seeking behavior.

Objective

We hypothesized that VAS scores would be higher and show less serial improvement for patients with a history of frequent ED use.

Methods

This was a prospective, observational cohort study of a convenience sample of adult ED patients with chief complaint of pain. Initial VAS scores were recorded. Pain scores were subsequently updated 30–45 min after pain medication administration. ED frequenter defined as having >4 ED visits over a 1-year time period. Categorical data analyzed by chi-square; continuous data analyzed by t-tests. A multiple linear regression performed to control for confounding.

Results

125 patients were enrolled; 51% ED frequenters. ED frequenters were similar to non-ED frequenters with respect to gender, mean age, Hispanic race, educational level, chief complaint type, and initial pain medication narcotic. ED frequenters more likely to have higher initial VAS score (9.17+/-1.25 vs. 8.51+/-1.68; p = 0.01) and higher second VAS scores (7.48+/-2.56 vs. 5.00+/-3.28; p <0.001) and significantly lower mean change in first to second VAS scores (1.69+/-2.17 vs. 3.51+/-3.25; p <0.001). Within our multiple linear regression model, only ED frequenter group (p < 0.001) and private insurance status (0.04) were associated with differences in mean reduction in pain scores.

Conclusion

We found that ED frequenters had significantly less improvement between first and second VAS measurements.

Improving paediatric pain management in the emergency department: An integrative literature review

BACKGROUND

Children presenting to the emergency department continue to experience suboptimal pain management. While evidence-based pain management interventions are available to clinicians, effective and sustainable practice change is yet to be achieved. This practice gap requires a collaborative approach to knowledge translation targeting systems of care.

OBJECTIVES

The purpose of this review was to explore systems level change in the emergency department for improved paediatric pain management.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, Embase, PubMed/Medline, Dynamed, Cochrane, Scopus, Prospero and Joanna Briggs Institute were systematically searched, and clinical guidelines and reference lists scanned.

REVIEW METHODS

Studies were screened and selected according to the inclusion criteria, and independently appraised for risk of bias. Integrative review methodology informed data extraction and synthesis, focused on organisational context and engagement, facilitation and implementation of practice change, key components of the pain management interventions, and evaluation.

RESULTS

Twenty studies met the inclusion criteria: 18 uncontrolled pretest-posttest and two pseudo-randomised design. Study populations ranged from children with a specific presentation, to all presenting children. All studies adopted a multifaceted approach to organisational change, bundling various interventions including pain assessment tools and management protocols, clinician education, nurse-initiated analgesia, feedback and family engagement. Four studies used local systems analysis to inform interventions and two studies applied an implementation framework. Time to analgesia was the most commonly improved primary outcome. Parent and child sensitive outcomes were assessed in five studies. Interventions that hold the most promise for optimised pain management if embedded in the workplace include nurse-initiated analgesia and family involvement at each stage of pain management in the emergency department.

CONCLUSION

The way forward is to respectfully engage all stakeholders-children, parents and clinicians-to collaboratively develop evidence-based, sustainable solutions aligned with the emergency department context. Guided by an implementation framework, future research designed to creatively translate evidence into practice and facilitate change at a systems level is a priority. Key to this solution is the integration of family involvement in pain management, considering child and family sensitive outcome measures. Effectiveness of new interventions should be evaluated in the short and long term to embed sustainable practice change. Frontline nurses are well placed to lead this transformation in paediatric pain management in the emergency department.

Implementation of paediatric pain care-bundle across South-West England clinical network of Emergency Departments and Minor Injury Units: A before and after study

INTRODUCTION

Pain management in children is often poorly executed in Emergency Departments and Minor Injury Units. The aim of this study was to assess the impact of a care bundle comprising targeted education on pain score documentation and provision of appropriately dosed analgesia for the paediatric population attending Emergency Departments (EDs) and Minor Injury Units (MIUs).

METHODS

A total of 29 centres - 5 EDs and 24 MIUs - participated in an intervention study initiated by Emergency Nurse Practitioners to improve paediatric pain management. In Phase 1, up to 50 consecutive records of children under 18 presenting at each MIU and ED were examined (n = 1201 records); Pain Score (PS), age, whether the child was weighed, and provision of analgesia was recorded. A care bundle consisting of an education programme, paediatric dosage chart and flyers, was then introduced across the 29 centres. Nine months following introduction of the care bundle, the same data set was collected from units (Phase 2, n = 1090 records).

RESULTS

The likelihood of children having a pain score documented increased significantly in Phase 2 (OR 6.90, 95% CI 5.72-8.32), The likelihood of children receiving analgesia also increased (OR1.82, 95% CI 1.51-2.19), although there was no increase in the proportion of children with moderate or severe pain receiving analgesia. More children were weighed following the care bundle (OR 2.58 95% CI 1.86-3.57). Infants and children who were not weighed were more likely to receive an incorrect analgesia dose (p < 0.01).

CONCLUSIONS

Rates of PS documentation improved and there was greater provision of analgesia overall following introduction of the care bundle. Although weighing of children did improve, the levels remain disappointingly low. EDs generally performed better than MIUs. The results show there were some improvements with this care bundle, but future work is needed to determine why pain management continues to fall below expected standards and how to further improve and sustain the impact of the care bundle.