An intervention to improve pain management in the pediatric emergency department

Education interventions and emergency nurses' clinical practice behaviours: A scoping review

BACKGROUND

Many education interventions in emergency nursing are aimed at changing nurse behaviours. This scoping review describes and synthesises the published research education interventions and emergency nurses' clinical practice behaviours.

METHODS

Arksey and O'Malley's methodological framework guided this review, which is reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). CINAHL, MEDLINE complete, ERIC, and Psycinfo were searched on 3 August 2023. Two pairs of researchers independently conducted all screening. Synthesis was guided by the Behaviour Change Wheel and Bloom's Taxonomy of Educational Objectives.

RESULTS

Twenty-five studies were included. Educational interventions had largely positive effects on emergency nurses' clinical practice behaviours. Ten different interventions were identified, the most common was education sessions (n = 24). Seven studies reported underpinning theoretical frameworks. Of the essential elements of behaviour change, seven interventions addressed capability, four addressed motivation and one addressed opportunity. Mapping against Bloom's taxonomy, thirteen studies addressed analysis, eleven studies addressed synthesis and two studies addressed evaluation.

CONCLUSION

Few studies addressed elements of behaviour change theory or targeted cognitive domains. Future studies should focus on controlled designs, and more rigorous reporting of the education intervention(s) tested, and theoretical underpinning for intervention(s) selected.

Impact of a Strategy for Improving Early Management of Acute Pain in the Pediatric Emergency Department

OBJECTIVES

The objective of this study was to measure the impact of an intervention on pain treatment in a pediatric emergency department (ED). The application of interventions to improve pain management in DE has demonstrated diverse effects so far, most of them successful.

METHODS

This is a quasi-experimental before-and-after, longitudinal, prospective study.Patients were collected between January 2020 and December 2021. Principal outcome was the number of patients with moderate or severe pain who received analgesia before 30 minutes to the ED arrival. The intervention consisted of several training sessions for nursing staff, pediatricians, and trauma physicians.

RESULTS

A total of 515 patients were enrolled, 230 during preintervention period and 285 during postintervention period. The percentage of patients receiving analgesia before 30 minutes increased from 24% to 29% and before 60 minutes increased from 31% to 42%. Time to analgesia administration decreased from 43 to 39 minutes.Only 254 patients (49%) received analgesia at some point during their stay in the ED, 137 (26.6%) before 30 minutes and 193 (37.5%) before 60 minutes. The probability of receiving analgesia was greater in patients seen by a pediatrician rather than an orthopedist (59%-37%). Metamizole was the most commonly used drug (48%), followed by ibuprofen and acetaminophen.

CONCLUSIONS

The application strategies to enhance early pain treatment in the ED can improve analgesia administration. Training strategies aimed at healthcare personnel working in the ED can change the way they work and achieve clear benefits for the patient. The treatment of pain in the ED should begin as soon as possible, and in this objective, the involvement of the nursing staff is a priority, because they are the professional who has the best opportunity for the detection and treatment of pain from the moment of triage.

Practice Patterns and Assessment of Needs for Pediatric Pain Management in Alberta Emergency Departments

Purpose

Many rural and community emergency departments (EDs) experience barriers to providing optimal pain care to children. In preparation for a quality improvement initiative, our team conducted a provincial pediatric pain management practice and needs assessment.

Methods

An online survey was sent to ED administrators and educators from March to May 2017. Themes included pain assessment, pain and distress management strategies, available resources, education, barriers to care, and opportunities for improvement.

Results

Forty-five respondents, from 31 EDs representing all five geographic health zones in Alberta, completed the survey. Use of a pain assessment tool was reported at 93.5% (29/31 sites) of the sites. Topical anesthesia was employed “most of the time” before suturing at 67% (18/27) of sites, versus 15% (4/27) before blood work or IV insertion. Eighty-one percent (22/27) of sites reported physically restraining children for procedures “often”, while 37% (10/27) reported use of comfort positioning “often”. Digital distraction devices were available at 37% (10/27) of sites. Reported challenges included lack of resources (33.3%, 12/36), staff education/knowledge (33.3%, 12/36), and absent policies/poor policy adherence (25.0%, 9/36). Opportunities for improvement included staff member education (73.5%, 25/34) and more resources (58.8%, 20/34). Respondents rated their site’s overall ability to manage children’s pain as 50/100 [IQR:21,61].

Conclusion

General EDs report providing suboptimal children’s pain care, with use of physical restraint for medical procedures, and under-utilization of evidence-based, inexpensive treatment options. There are many gaps in children’s pain care in rural and community EDs which could be addressed through collaborative quality improvement initiatives.

Investigating the use of physical restraint of children in emergency departments: A Scandinavian survey

AIM

The aim of the study is to describe the current frequency of physical restraint and the use of analgesics and sedatives for treating pediatric pain in emergency departments (EDs) in Scandinavia.

METHODS

We performed a nation-wide electronic survey asking nurses in the emergency departments in Denmark, Norway, and Sweden about their experience treating children in pain.

RESULTS

Responses from 103 Danish, Norwegian and Swedish nurses were included (79% response rate). Physical restraint was reported used at 79% [70.0-85.9] (N = 78) of the surveyed departments (DK: 96%, NO: 67%, SE: 77%) with two participants reporting daily use of physical restraint. Paracetamol was available at all departments and used most frequently. Sedation was available at 88% [78.8-92.0] of the departments with midazolam as the most recurrent sedative (83%, [74.8-89.4]). Seventy-three percent of respondents reported a need for better treatments. Lack of education was the most frequently reported obstacle for providing both pain treatment (29%) and sedation (43%) followed by lack of guidelines.

CONCLUSION

Physical restraint of children during painful procedures is used in the majority of Scandinavian emergency departments (79%). There appears to be a lack of local guidelines for both pain treatment and sedation.

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.

A Systematic Literature Review of Child Life in Ambulatory Settings

This article illustrates the growth and development of the profession of child life within the last 25 years through a literature review of child life services in ambulatory settings. We reviewed all literature chronicling child life services in ambulatory settings published between January 1993 and December 2018 in three major databases, synthesizing common themes across the literature. Over the last 25 years, growth has occurred in the provision of child life interventions in outpatient settings and more publications are being produced. In outpatient settings, procedural support interventions have been written about the most, with much of this literature coming after 2010. [Pediatr Ann. 2020;49(11):e491-e498.].

Diagnostic accuracy of ultrasound for upper extremity fractures in children: A systematic review and meta-analysis

OBJECTIVE

Ultrasound has an excellent diagnostic accuracy for fractures that is reportedly comparable to plain radiographs. We aim to summarize the diagnostic accuracy of ultrasound for upper extremity fractures in children.

METHODS

Databases were searched from inception through November 2019 using pre-defined index terms, including "ultrasound," "fractures of upper extremities" and "children". The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for fractures was conducted using the random-effects bivariate model. Subgroup analysis of fracture site (elbow vs non-elbow fractures) was also performed. Meta-regression was performed to determine if the site of fracture affected the diagnostic accuracy.

RESULTS

Thirty-two studies were identified in the meta-analysis. Ultrasound for fractures of the upper extremities has a sensitivity: 0.95 (95% CI: 0.93-0.97), specificity: 0.95 (95% CI: 0.91-0.98), positive likelihood ratio: 21.1 (95% CI: 10.8-41.5) and negative likelihood ratio: 0.05 (95% CI: 0.03-0.07), with an area under ROC (AUROC) curve of 0.98 (95% CI: 0.97-0.99). Subgroup analysis for elbow fracture showed ultrasound has a sensitivity: 0.95 (95% CI: 0.86-0.98), specificity: 0.87 (95% CI: 0.76-0.94), positive likelihood ratio: 7.3 (95% CI: 3.7-14.4) and negative likelihood ratio: 0.06 (95% CI: 0.02-0.16), with an AUROC of 0.96 (95% CI: 0.94-0.97). Meta-regression suggested the fracture sites would affect diagnostic accuracy of ultrasound (elbow vs non-elbow, p < 0.01).

CONCLUSIONS

Current evidence suggests ultrasound has excellent diagnostic accuracy for non-elbow upper extremity fractures in children, serving as an alternative diagnostic modality to plain radiographs.

Pediatric Pain Management in Plastic Surgery

Adequate pediatric pain management is difficult to achieve for a variety of reasons. Pain assessment is more difficult in the pediatric population. There are a variety of different tools that may be used to accurately assess pain. There are many modalities to achieve pain control, including pharmacologic and nonpharmacologic means. These different modalities should be used in unison to achieve pain control. Compartment syndrome is a surgical emergency, and pediatric patients present differently from adult patients. The 3 As (anxiety, agitation, increase in analgesia requirement) should be monitored in all pediatric patients.

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.

Procedural pain in children: a qualitative study of caregiver experiences and information needs

BACKGROUND

Children experience multiple painful procedures when being cared for in emergency departments (EDs). Unfortunately, evidence-based interventions to manage such pain and distress are under-utilized across EDs. Caregivers are uniquely positioned and invested to advocate for the adaptation of such evidence into practice. Our objective was to gather information from caregivers of children experiencing procedural pain in the ED to inform the development of a novel, caregiver-focused knowledge translation (KT) tool.

METHODS

The study design was qualitative description. Caregivers of children who underwent intravenous (IV) insertion or venipuncture in the pediatric ED at an urban tertiary care centre were interviewed. Thematic analysis was applied to the data. The TRanslating Emergency Knowledge for Kids (TREKK) Parent Advisory Group continuously informed this study, and provided input on interview guide development and piloting, data collection, analysis of the data, interpretation of the results, and development of next steps.

RESULTS

Interviews revealed four major themes: 1) source of healthcare information; 2) delivering healthcare information; 3) communication with caregivers; and 4) procedure-related anxiety and long-term effects. Caregivers most valued receiving information directly from their healthcare provider. They also expressed that healthcare providers should direct information about the procedure to their child and identified strategies to involve children in their care. Caregivers wanted to be empowered to ask informed questions of their healthcare providers. Finally, caregivers reported negative experiences with procedures for their children, occurring mainly at non-pediatric centres.

CONCLUSIONS

We have identified core information needs for caregivers whose children are experiencing IV insertion or venipuncture. These results will form the foundation for the development of a KT tool that may empower caregivers to actively participate in their child's healthcare.

Pediatric Pain Management

Nearly 20 years ago, standards were established for hospitals to assess and treat pain in all patients. Research continues to demonstrate evolving trends in the measurement and effective treatment of pain in children. Behavioral research demonstrating long-lasting effects of inadequate pain control during childhood supports the concepts of early and adequate pain control for children suffering from painful conditions in the acute care setting. The authors discuss pain concepts, highlighting factors specific to the emergency department, and include a review of evidence for pharmacologic and nonpharmacologic treatments.

Ambient versus traditional environment in pediatric emergency department

OBJECTIVE

We sought to examine the effect of exposure to an ambient environment in a pediatric emergency department. We hypothesized that passive distraction from ambient lighting in an emergency department would lead to reduction in patient pain and anxiety and increased caregiver satisfaction with services.

BACKGROUND

Passive distraction has been associated with lower anxiety and pain in patients and affects perception of wait time. A pediatric ED was designed that optimized passive distraction techniques using colorful ambient lighting.

METHODS

Participants were nonrandomly assigned to either an ambient ED environment or a traditional ED environment. Entry and exit questionnaires assessed caregiver expectations and experiences. Pain ratings were obtained with age-appropriate scales, and wait times were recorded.

RESULTS

A total of 70 participants were assessed across conditions, that is, 40 in the ambient ED group and 30 in the traditional ED group. Caregivers in the traditional ED group expected a longer wait, had higher anxiety pretreatment, and felt more scared than those in the ambient ED group. Caregivers in the ambient ED group felt more included in the care of their child and rated quality of care higher than caregivers in the traditional ED group. Pain ratings and administrations of pain medication were lower in the ambient ED group.

CONCLUSIONS

Mean scores for the ambient ED group were in the expected direction on several items measuring satisfaction with ED experiences. Results were suggestive of less stress in caregivers, less pain in patients, and higher satisfaction levels in the ambient ED group.

The Effects of Child Life Specialists on Success Rates of Intravenous Cannulation

BACKGROUND

Child life specialists (CLS) work with children directly to minimize long-term psychological sequelae of traumatic or medical events such as intravenous cannulation. There has been little done to measure how CLS impact outcomes of medical procedures. The objective of this study is to determine the impact of interventions by CLS upon successful attainment of intravenous (IV) cannulation among pediatric patients in the emergency department setting.

METHOD

This was an eight month retrospective review within an urban tertiary-care freestanding pediatric Emergency Department (ED), using nursing and CLS documentation of ED patients younger than 21years who underwent IV cannulation. CLS self selected which children received procedural support, and the duration of CLS staffing was not a full 24h. Children with CLS documentation were compared against those without documented interventions by CLS. IV cannulation success and number of IV cannulation attempts were the primary outcomes. Confounding variables such as location of intravenous site, intravenous gauge, and professional qualifications were added. Chi-square determined the impact of CLS on primary outcomes. Logistic regression examined the association between successful IV cannulation with age.

RESULTS

In all, 5460 children had documented IV cannulation, and 240 of those received CLS intervention. CLS intervention was not associated with IV cannulation success (p=0.5). The only significant association for successful IV cannulation was intravenous site (p<0.001). There was no interaction effect between patient age and CLS (p=0.12).

CONCLUSION

Interventions by CLS do not affect the procedural outcome of intravenous cannulation success. Benefits of CLS are likely better measured in psychological impact of anxiolysis and improved experience, rather than in procedural outcome.

Publishing Trends in the Field of Pediatric Emergency Medicine From 2004 to 2013

OBJECTIVE

To identify publishing trends within the field of pediatric emergency medicine between 2004 and 2013.

METHODS

We conducted a MEDLINE search of pediatric emergency medicine articles, filtered by clinical trial, published between 2004 and 2013 in ten journals from the fields of pediatrics, emergency medicine, general medicine, and pediatric emergency medicine. Each article was classified by journal type, study design, results (positive or negative/equivocal), age/type of subjects, and major topic (based on the objective of the study). Articles were stratified by publication period (2004-2008 or 2009-2013) to analyze trends.

RESULTS

A total of 464 articles were analyzed. The majority of articles were described as randomized-controlled trials (47%) with negative/equivocal findings (70%). The most common major topics were pain management, asthma, sedation, bronchiolitis, resuscitation, simulation, and ultrasound. Over time, the percentage of articles published in pediatrics and pediatric emergency medicine journals increased (P = 0.0499) and the percentage for all study designs increased except for randomized controlled trials (P = 0.0089). There were no differences between the 2 publication periods when stratified by results, age/type of subjects, and major topic.

CONCLUSIONS

By identifying these trends, we hope to encourage researchers to perform studies in the field of pediatric emergency medicine where deficiencies lie and to guide pediatric health care professionals to where published, evidence-based studies can be found in the medical literature.

Pain management of acute appendicitis in Canadian pediatric emergency departments

OBJECTIVES

Children with suspected appendicitis are at risk for suboptimal pain management. We sought to describe pain management patterns for suspected appendicitis across Canadian pediatric emergency departments (PEDs).

METHODS

A retrospective medical record review was undertaken at 12 Canadian PEDs. Children ages 3 to 17 years who were admitted to the hospital in February or October 2010 with suspected appendicitis were included. Patients were excluded if partially assessed or treated at another hospital. Data were abstracted using a study-specific, standardized electronic data extraction tool. The primary outcome was the proportion of children who received analgesia while in the emergency department (ED). Secondary outcomes included the proportion of children receiving intravenous (IV) morphine and the timing of analgesic provision.

RESULTS

A total of 619 health records were abstracted; mean (SD) patient age was 11.4 (3.5) years. Sixty-one percent (381/616) of patients received analgesia in the ED; 42.8% (264/616) received IV morphine. Other analgesic agents provided included oral acetaminophen (23.5% [145/616]) and oral ibuprofen (5.8% [36/616]). The median (IQR) initial dose of IV morphine was 0.06 (0.04, 0.09) mg/kg. The median (IQR) time from triage to the initial dose of analgesia was 196 (101, 309.5) minutes. Forty-three percent (117/269) of children receiving analgesia received the initial dose following surgical consultation; 43.7% (121/277) received their first analgesic after abdominal ultrasound was performed.

CONCLUSIONS

Suboptimal and delayed analgesia remains a significant issue for children with suspected appendicitis in Canadian PEDs. This suggests a role for multidimensional knowledge translation interventions and care protocols to improve timely access to analgesia.

Nationwide study of headache pain in Italy shows that pain assessment is still inadequate in paediatric emergency care

Aim

Italian national guidelines on pain management were published in 2010, but there is little information on how effective pain management is in paediatric emergency care, with other countries reporting poor levels. Using headache as an indicator, we described pain assessment in Italian emergency departments and identified predictors of algometric scale use.

Methods

All Italian paediatric and maternal and child hospitals participated, plus four general hospitals. Data on all children aged 4–14 years admitted during a one‐month period with headache as their chief complaint were abstracted from clinical records. Multivariable analyses identified predictors of algometric assessment, taking into account the cluster study design.

Results

We studied 470 admissions. During triage, pain was assessed using a standardised scale (41.5%), informally (15.5%) or was not recorded (42.9%). Only 32.1% of the children received analgesia in the emergency department. The odds ratios for predictors of algometric assessment were non‐Italian nationality (3.6), prehospital medication (1.8), admission to a research hospital (7.3) and a more favourable nurses‐to‐admissions ratio of 10.8 for the highest versus lowest tertile.

Conclusion

Despite national guidelines, paediatric pain assessment in Italian emergency care was suboptimal. Hospital variables appeared to be stronger predictors of adequate assessment than patient characteristics.

Reported practice variation in pediatric pain management: a survey of Canadian pediatric emergency physicians

OBJECTIVES

To describe pediatric emergency medicine (PEM) physicians' reported pain management practices across Canada and explore factors that facilitate or hinder pain management.

METHODS

This study was a prospective survey of Canadian pediatric emergency physicians. The Pediatric Emergency Research Canada physician database was used to identify participants, and a modified Dillman's Total Design Survey Method was used for recruitment.

RESULTS

The survey response rate was 68% (139 of 206). Most physicians were 31 to 50 years old (82%) with PEM training (56%) and had been in practice for less than 10 years (55%). Almost all pain screening in emergency departments (EDs) occurred at triage (97%). Twenty-four percent of physicians noted institutionally mandated pain score documentation. Ibuprofen and acetaminophen were commonly prescribed in the ED for mild to moderate pain (88% and 83%, respectively). Over half of urinary catheterizations (60%) and intravenous (53%) starts were performed without any analgesia. The most common nonpharmacologic interventions used for infants and children were pacifiers and distraction, respectively. Training background and gender of physicians affected the likelihood of using nonpharmacologic interventions. Physicians noted time restraints to be the greatest barrier to optimal pain management (55%) and desired improved access to pain medications (32%), better policies and procedures (30%), and further education (25%).

CONCLUSIONS

When analgesia was reported as provided, ibuprofen and acetaminophen were most commonly used. Both procedural and presenting pain remained suboptimally managed. There is a substantial evidence practice gap in children's ED pain management, highlighting the need for further knowledge translation strategies and policies to support optimal treatment.

Current concepts in management of pain in children in the emergency department

Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

Variables associated with parent satisfaction with their child's pain management

OBJECTIVE

The provision of 'adequate analgesia' (which reduces the pain score by ≥2 and to <4 [0-10 scale]) is significantly associated with high levels of satisfaction with pain management among adult patients. We aimed to determine the variables (including 'adequate analgesia') associated with parent satisfaction with their child's pain management.

METHODS

We undertook an observational, pilot study in a mixed, metropolitan ED. Patients aged 4-16 years with a triage pain score of ≥4 were enrolled. Data included demographics, presenting complaint, pain scores every 30 min, analgesia administered, time to first analgesia, provision of nurse-initiated analgesia (NIA), and 'adequate analgesia', and parent satisfaction 48-h post-discharge (6 point scale: very unsatisfied - very satisfied).

RESULTS

Complete data were collected on 185 patients: mean (SD) age 10.4 (3.6) years, weight 41.9 (17.8) kg; 93 (50.3%) were male. One hundred and ten (59.4%) parents were very satisfied with their child's pain management. Children of very satisfied parents had shorter times to analgesia than those who did not (median [interquartile range] 14 (33) vs 33 (46) min, respectively, P = 0.003). Parents whose children received NIA or 'adequate analgesia' were more often very satisfied than those whose children did not. However, the differences were not significant (difference in proportions: 13.2% [95% CI -1.9, 28.3], P = 0.07 and 10.2% [95% CI -5.02, 25.34], P = 0.16, respectively).

CONCLUSION

Short times to analgesia are associated with parent satisfaction. There were non-significant trends towards high levels of satisfaction following the provision of NIA and 'adequate analgesia'. These findings will inform a well-powered study to confirm this association.

Analgesia for fracture pain in children: methodological issues surrounding clinical trials and effectiveness of therapy

Fractures in childhood are common painful conditions. Suboptimal analgesia has been reported in the emergency department and following discharge. Recently, concern about the safety of narcotics such as codeine has sparked a renewed interest in opioids such as morphine for pediatric fracture pain. Consequently, opioids are being increasingly used in the clinical setting. Despite this, there is ample evidence that clinicians are more willing to offer opioids to adults than children. The existence of limited evidence supporting their use in children is likely a major contributing factor. A closer look at the limitations of designing high-quality analgesic trials in children with fractures is needed to enable investigators to anticipate problems and clinicians to make evidence-based choices.

Improving postoperative pain management in children by providing regular training and an updated pain therapy concept

BACKGROUND

In recent years, children's hospitals have increasingly implemented postoperative pain management protocols to reduce postoperative pain and improve patient satisfaction. The effectiveness and long-term sustainability of such protocols have rarely been studied. Therefore, we conducted a prospective intervention study to assess the impact of regular training and improvement of clinical processes on the quality of postoperative pain management.

METHODS

We conducted an initial assessment of the status quo of postoperative pain management (Audit 1) followed by repeated training and improvement of clinical processes (analgesic pocket card, parents' brochure, modification of the patient chart, bimonthly advanced trainings sessions) and a follow-up review after 3 years (Audit 2). We used a data entry form, a patient survey, and an anonymous questionnaire for the nursing staff as measurement tools.

RESULTS

Our analysis included a total of 93 and 85 patients in the initial and final audits. The return rates of the nursing staff questionnaire were 83% (Audit 1) and 77% (Audit 2). The training and process improvements resulted in significant improvement in the administration of analgesics for pain requiring treatment, the control of pain measurement after the administration of analgesics and the use of non-pharmacological pain therapies. The patients reported faster administration of analgesics for acute pain and improved pain relief following the intervention.

CONCLUSIONS

Repeated training and improvement of clinical processes can significantly improve the long-term quality of postoperative pain management in children with a tolerable amount of effort on the part of health care professionals and institutions.

A Survey of Caregiver Perspectives on Children's Pain Management in the Emergency Department

OBJECTIVES

We explored caregiver perspectives on their children's pain management in both a pediatric (PED) and general emergency department (GED). Study objectives were to: (1) measure caregiver estimates of children's pain scores and treatment; (2) determine caregiver level of satisfaction; and (3) determine factors associated with caregiver satisfaction.

METHODS

This prospective survey examined a convenience sample of 97 caregivers (n=51 PED, n=46 GED) with children aged <17 years. A paper-based survey was distributed by research assistants, from 2009-2011.

RESULTS

Most caregivers were female (n=77, 79%) and were the child's mother (n=69, 71%). Children were treated primarily for musculoskeletal pain (n=41, 42%), headache (n=16, 16%) and abdominal pain (n=7, 7%). Using a 100 mm Visual Analog Scale, the maximum mean reported pain score was 75 mm (95% CI: 70-80) and mean score at discharge was 39 mm (95% CI: 32-46). Ninety percent of caregiver respondents were satisfied (80/89, 90%); three (3/50, 6%) were dissatisfied in the PED and six (6/39, 15%) in the GED. Caregivers who rated their child's pain at ED discharge as severe were less likely to be satisfied than those who rated their child's pain as mild or moderate (p=0.034).

CONCLUSIONS

Despite continued pain upon discharge, most caregivers report being satisfied with their child's pain management. Caregiver satisfaction is likely multifactorial, and physicians should be careful not to interpret satisfaction as equivalent to adequate provision of analgesia. The relationship between satisfaction and pain merits further exploration.

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

OBJECTIVES

The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies.

METHODS

Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression.

RESULTS

Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014).

CONCLUSIONS

Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.

Multiple interventions improve analgesic treatment of supracondylar humerus fractures in a pediatric emergency department

BACKGROUND

Provision of appropriate and timely treatment for pain in the pediatric population has been challenging. Children with painful conditions commonly present to emergency departments (EDs), a setting in which it may be particularly difficult to consistently provide timely analgesic interventions.

OBJECTIVES

To measure the effectiveness of a set of interventions in improving the rate and timeliness of analgesic medication administration, as well as appropriate backslab immobilization (application of a moldable plaster or fiberglass splint), in a pediatric ED.

METHODS

Data regarding pain management were collected on a consecutive sample of cases of supracondylar fracture over a 13-month period. This followed the implementation of a formal triage pain assessment and treatment medical directive, supplemented with relevant education of nursing and house staff, and posters in the ED. These data were compared with data previously collected from a similar cohort of cases, which presented before the interventions.

RESULTS

Postintervention, the proportion of patients treated with an analgesic within 60 min of triage increased from 15% to 54% (P<0.001), and the median time to administration of an analgesic decreased from 72.5&nbsp;min to 11 min (P<0.001). Rates for backslab application before radiography were similar before and after the intervention (29% and 33%, respectively; P=0.646).

CONCLUSIONS

A multifaceted approach to improving early analgesic interventions was associated with considerably improved rates of early analgesic treatments for supracondylar fracture; however, no improvement in early immobilization was observed.

Paediatric pain management practice and policies across Alberta emergency departments

BACKGROUND

Many children requiring acute care receive suboptimal analgesia.

OBJECTIVES

To describe paediatric pain management practices and policies in emergency departments (EDs) in Alberta.

METHODS

A descriptive survey was distributed to each of the EDs in Alberta.

RESULTS

A response rate of 67% (72 of 108) was obtained. Seventy-one percent (42 of 59) of EDs reported the use of a pain tool, 29.3% (17 of 58) reported mandatory pain documentation and 16.7% (10 of 60) had nurse-initiated pain protocols. Topical anesthetics were reported to be used for intravenous line insertion by 70.4% of respondents (38 of 54) and for lumbar puncture (LP) by 30.8% (12 of 39). According to respondents, infiltrated anesthetic was used for LP by 69.2% (27 of 39) of respondents, and oral sucrose was used infrequently for urinary catheterization (one of 46 [2.2%]), intravenous line insertion (zero of 54 [0%]) and LP (one of 39 [2.6%]).

CONCLUSIONS

Few Alberta EDs use policies and protocols to manage paediatric pain. Noninvasive methods to limit procedural pain are underutilized. Canadian paediatricians must advocate for improved analgesia to narrow this knowledge-to-practice gap.

Critical appraisal of emergency medicine education research: the best publications of 2012

OBJECTIVES

The objective was to critically appraise and highlight medical education research published in 2012 that was methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine (EM).

METHODS

A search of the English language literature in 2012 querying Education Resources Information Center (ERIC), PsychInfo, PubMed, and Scopus identified EM studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. This year, publications limited to a single-site survey design that measured satisfaction or self-assessment on unvalidated instruments were not formally reviewed. Six reviewers then independently ranked all remaining publications using one of two scoring systems depending on whether the study methodology was primarily qualitative or quantitative. Each scoring system had nine criteria, including four related to methodology, that were chosen a priori, to standardize evaluation by reviewers. The quantitative study scoring system was used previously to appraise medical education published annually in 2008 through 2011, while a separate, new qualitative study scoring system was derived and implemented consisting of parallel metrics.

RESULTS

Forty-eight medical education research papers met the a priori criteria for inclusion, and 33 (30 quantitative and three qualitative studies) were reviewed. Seven quantitative and two qualitative studies met the criteria for inclusion as exemplary and are summarized in this article.

CONCLUSIONS

This critical appraisal series aims to promote superior education research by reviewing and highlighting nine of the 48 major education research studies with relevance to EM published in 2012. Current trends and common methodologic pitfalls in the 2012 papers are noted.

Development of an outcome measure to monitor the effectiveness of pain management

Attention to the pain that occurs during treatments and procedures for pediatric patients with cancer continues to be a priority. This article describes the development of a pain effectiveness outcome measure at an academic pediatric medical center in order to inform about the implementation of quality improvement strategies and evaluate the effect of these pain interventions within the hospital setting.

Pain management policies and practices in pediatric emergency care: a nationwide survey of Italian hospitals

BACKGROUND

Pain experienced by children in emergency departments (EDs) is often poorly assessed and treated. Although local protocols and strategies are important to ensure appropriate staff behaviours, few studies have focussed on pain management policies at hospital or department level. This study aimed at describing the policies and reported practices of pain assessment and treatment in a national sample of Italian pediatric EDs, and identifying the assocoated structural and organisational factors.

METHODS

A structured questionnaire was mailed to all the 14 Italian pediatric and maternal and child hospitals and to 5 general hospitals with separate pediatric emergency room. There were no refusals. Information collected included the frequency and mode of pain assessment, presence of written pain management protocols, use of local anaesthetic (EMLA cream) before venipuncture, and role of parents. General data on the hospital and ED were also recorded. Multiple Correspondence Analysis was used to explore the multivariable associations between the characteristics of hospitals and EDs and their pain management policies and practices.

RESULTS

Routine pain assessment both at triage and in the emergency room was carried out only by 26% of surveyed EDs. About one third did not use algometric scales, and almost half (47.4%) did not have local protocols for pain treatment. Only 3 routinely reassessed pain after treatment, and only 2 used EMLA. All EDs allowed parents' presence and most (17, 89.9%) allowed them to stay when painful procedures were carried out. Eleven hospitals (57.9%) allowed parents to hold their child during blood sampling. Pediatric and maternal and child hospitals, those located in the North of Italy, equipped with medico-surgical-traumatological ED and short stay observation, and providing full assessment triage over 24 hours were more likely to report appropriate policies for pain management both at triage and in ER. A nurses to admissions ratio ≥ median was associated with better pain management at triage.

CONCLUSIONS

Despite availability of national and international guidelines, pediatric pain management is still sub-optimal in Italian emergency departments. Multifaceted strategies including development of local policies, staff educational programs, and parental involvement in pain assessment should be carried out and periodically reinforced.

A comprehensive view of parental satisfaction with pediatric emergency department visits

STUDY OBJECTIVE

We develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric emergency department (ED) visits, using both quantitative and qualitative data.

METHODS

This was a retrospective observational study using data from an institution-wide system to measure patient satisfaction. For this study, 2,442 parents who brought their child to the ED were interviewed with telephone survey methods. The survey included closed-ended (quantitative) and open-ended (qualitative data) questions, in addition to a cognitive interview-style question.

RESULTS

Overall parental satisfaction was best predicted by how well physicians and nurses work together, followed by wait time and pain management. Issues concerning timeliness of care, perceived quality of medical care, and communication were raised repeatedly by parents in response to open-ended questions. A cognitive interview-style question showed that physicians and nurses sharing information with each other, parents receiving consistent and detailed explanations of their child's diagnosis and treatments, and not having to answer the same question repeatedly informed parent perceptions of physicians and nurses working well together. Staff showing courtesy and respect through compassion and caring words and behaviors and paying attention to nonmedical needs are other potential satisfiers with emergency care.

CONCLUSION

Using qualitative data to augment and clarify quantitative data from patient experience of care surveys is essential to obtaining a complete picture of aspects of emergency care important to parents and can help inform quality improvement work aimed at improving satisfaction with care.