Association of pain score documentation and analgesic use in a pediatric emergency department

Pediatric and emergency medicine resident comfort assessing and treating pediatric pain across pediatric age groups

Aim: Assess pediatric and emergency medicine (EM) resident comfort treating and assessing pediatric pain. Materials & methods: Pediatric and EM residents at a single institution (SIUH Northwell Health in New York) completed an anonymous survey 6 months into the academic year regarding comfort assessing and treating pediatric pain. Results: A total of 40 (16/24 EM and 24/24 pediatric) residents completed this survey: 20% (8/24) pediatric first year residents, 40% (16/40) pediatric second year and above, 20% (8/40) EM first year and 20% (8/40) EM second year and above. A 46% (11/24) pediatric and 12% (2/16) EM residents were comfortable assessing neonatal pain (p < 0.05). A 38% (9/24) pediatric residents were comfortable treating neonatal pain compared with 12% (2/16) EM residents (p < 0.05). Both resident groups reported increasing comfort assessing and treating pain with increasing patient age. Conclusion: Both residents groups reported limitations in comfort assessing and treating pediatric pain, especially in younger patients. Education for both groups is important to optimize pediatric pain management.

An assessment of the psychometric properties of the Stoplight Pain Scale in a Canadian paediatric emergency department

Objective

This study aimed to validate a novel, three faced, colour-coded, action-oriented tool: The Stoplight Pain Scale (SPS).

Methods

A prospective observational cohort study was conducted at a Canadian paediatric emergency department from November 2014 to February 2017. Patients aged 3 to 12 years and their caregivers were asked to rate pain using the SPS and the Faces Pain Scale-Revised (FPS-R). Pain was measured just before analgesia administration, 30 minutes after analgesia administration, and immediately following a painful procedure.

Results

A total of 227 patients were included; 26.9% (61/227) were 3 to 5 years old while 73.1% (166/227) were 6 to 12 years old. Using Cohen's κ, agreement for SPS and FPS-R was 'fair' for children (0.28 [95% confidence interval {CI} 0.20 to 0.36]) and 'poor' for caregivers (0.14 [95% CI 0.07 to 0.21]), at initial measurement. The SPS had 'fair' agreement between child and caregiver scores, (0.37 [95% CI 0.27 to 0.47]), compared to FPS-R which showed 'poor' agreement (0.20 [95% CI 0.12 to 0.29]). Absolute agreement between child and caregiver SPS scores improved with repeat exposure; 30 minutes after analgesia administration, caregivers and children had fair agreement (κ=0.38, 95% CI 0.28 to 0.48); they had moderate agreement directly following painful procedures (κ=0.46, 95% CI 0.34 to 0.59). Overall, 72.4% (139/192) of children and 60.2% (118/196) of caregivers preferred SPS over FPS-R.

Conclusion

The SPS demonstrates fair agreement with FPS-R for children and fair-moderate agreement between children and caregivers; agreement improved with repeat use. The SPS is simple and easy to use; it may have a role in empowering direct child and family involvement in pain management.

Blood pressure management in emergency department patients with spontaneous intracerebral hemorrhage

INTRODUCTION

Despite the well documented importance of blood pressure management in patients with spontaneous intracerebral hemorrhage (sICH), little is known about whether emergency departments (EDs) are able to achieve close monitoring and precise management. Our study characterizes ED monitoring and management of blood pressure in sICH patients.

METHODS

This is a retrospective study of adults with sICH and elevated intracranial pressure. Patients who were admitted from any referring ED to our CCRU from 1 August 2013 to 30 September 2015 were included. We graphically assessed the association between average minutes between blood pressure measurements and average minutes between administration of antihypertensives. We also performed logistic regression to evaluate factors associated with close blood pressure monitoring and the achievement of goal blood pressure in patients with sICH who presented with hypertension.

RESULTS

Of 115 patients, 73 presented to the ED with SBP above 160 mmHg. Length of stay in the ED was significantly associated with a longer period between blood pressure measurements. Longer periods between blood pressure measurements were a significant determinant of failure to achieve blood pressure goal in sICH patients. Longer periods between blood pressure measurements were significantly associated with longer periods between administration of antihypertensives.

CONCLUSION

Our study suggests that blood pressure monitoring is related to the frequency of blood pressure interventions and achievement of adequate blood pressure control in patients with sICH. There is significant variability in EDs' achievement of the recommended close blood pressure monitoring and management in patients with sICH.

The Complex Association of Race/Ethnicity With Pain Treatment Quality in an Urban Medical Center With 2 Pediatric Emergency Departments

OBJECTIVE

This study aimed to explore racial differences in analgesia quality.

METHODS

A retrospective cross-sectional study of 24,733 visits by individuals 21 years or younger with pain scores of 4 to 10 was performed using electronic medical records. We compared 2 process metrics, treatment with any analgesics within 60 minutes and treatment with opioids within 60 minutes, and one outcome metric, a reduction in pain score by 2 or more points within 90 minutes. Multivariable logistic regression adjusted for the effects of patient characteristics and health status. We also determined variations in analgesia quality among those with severe pain.

RESULTS

When compared with white children, black children were more likely to receive any analgesia (adjusted odds ratio [aOR], 1.94; 95% confidence interval, 1.71-2.21), but both blacks (aOR, 0.66; 0.51-0.85) and Hispanics (aOR, 0.56; 0.39-0.80) were less likely to receive opioids. Blacks were more likely to reduce their pain score (aOR, 1.50; 1.28-1.76).Among children with severe pain, both blacks and Hispanics were more likely to receive any analgesia (black: aOR, 2.05 [1.71-2.46]; Hispanic: aOR, 1.29 [1.05-1.59]), and Hispanic children were less likely to receive opioids (aOR, 0.58; 0.37-0.91). Again, black children were more likely to reduce their pain score (aOR, 1.42; 1.13-1.79).

CONCLUSIONS

The relationship between race/ethnicity and analgesia is complex. Although minority children were less likely to receive opioids, black children had better treatment outcomes. Future studies should explore clinical response to analgesia in addition to process measures to better understand if differential treatment may be justified to achieve equitable care outcomes.

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.

Multicentre emergency department study found that paracetamol and ibuprofen were inappropriately used in 83% and 63% of paediatric cases

AIM

The Pain Practice in Italian Paediatric Emergency Departments assessed how appropriately analgesic drugs were being used by Italian clinicians, based on national paediatric pain guidelines.

METHODS

This was a retrospective study that involved 17 Italian members of the Pain In Pediatric Emergency Rooms group. It comprised patients up to the age of 14 years who came to hospital emergency departments with pain and were treated with paracetamol, ibuprofen or opioids, such as codeine, tramadol and morphine.

RESULTS

We studied 1471 patients who were given 1593 doses of analgesics. The median time to administration of analgesia was 25 minutes. Opioids were used in 13.5% of the children, and usage increased with age and with more severe clinical conditions, such as trauma: 1.6% of children under two years, 5.9% aged 3-10 and 8.0% aged 11-14. Inappropriate doses of paracetamol, ibuprofen and opioids were used in 83%, 63% and 33% of cases, respectively. The patient's age was a critical determinant of the correct analgesic dosage; for every one-year increase in the patient's age, the probability of appropriate prescriptions rose 14.8%.

CONCLUSION

The appropriate use of paracetamol and ibuprofen for paediatric pain in Italian emergency departments was very poor, but improved with age.

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.

Factors influencing ED care of young children at-risk for clinically important traumatic brain injury

OBJECTIVES

Care decisions for young children presenting to the emergency department (ED) with head injury are often challenging (e.g. whether to obtain neuroimaging). We sought to identify factors associated with acute management of children at-risk for clinically important traumatic brain injury (ciTBI) and describe symptom management.

METHODS

Observational evaluation of children, ages 0-4years, presenting to a pediatric ED following minor head injury. Children with ≥1 risk element per the Pediatric Emergency Care Academic Research Network's decision rule were deemed "at-risk" for ciTBI. Clinician surveys regarding their initial clinical management were used to identify three care groups. Nonparametric tests analyzed group differences and logistic regression investigated associations of putative high-risk factors with neuroimaging.

RESULTS

Of 104 children enrolled: (i) 30 underwent neuroimaging, (ii) 59 were observed, and (iii) 15 were discharged following the clinician's initial patient exam. Children with a non-frontal scalp hematoma were more likely to receive immediate neuroimaging and children not acting like themselves per caregiver report were more likely to be initially observed, relative to the other care groups (p≤0.01). Among high-risk factors, altered mental status (OR 5.12, 95% CI 1.8-21.1), presence of ≥3 risk elements of the decision rule (OR 3.5, 95% CI 1.2-10.6), unclear skull fracture on exam (OR 31.3, 95% CI 5.4-593.8), and age<3months (OR 5.3, 95% CI 1.5-21.9) were associated with neuroimaging. No child had ciTBI. TBI symptoms (e.g. vomiting) were infrequently treated.

CONCLUSIONS

ED management varied for young children with similar risk stratification. Investigation of how age in concert with specific risk factors influences medical decision making would advance evidenced-based care.

Perceived language proficiency and pain assessment by registered and student nurses in native English-speaking and EAL children aged 4-7 years

AIMS AND OBJECTIVES

To identify the factors that influence decisions made by health professionals when assessing the pain of native English speaking and children whose English is an additional language.

BACKGROUND

Pain assessment in children is often poorly executed following acute injury. Whilst a range of pain assessment tools have been developed, little guidance is provided for assessing pain in children with English as an additional language.

DESIGN

Factorial survey design.

METHODS

Twenty minor injuries unit nurses and 20 children's nursing students participated in an electronic survey to make judgements on 12 scenarios describing a child attending a minor injuries unit following an incident, accompanied by a parent. Respondents had to decide the most important form of pain assessment, and whether they would ask a parent or an interpreter to assess the pain of the child. An open-ended question asked about the difficulties found in making a judgement.

RESULTS

Observation of the child's behaviour was the most common pain assessment reported. The visual analogue scale was significantly associated with children with proficient English. Respondents were significantly more likely to involve parents in the assessment if they could speak English well compared to parents with poor English skills. Moreover, nursing students were significantly more likely than registered nurses to call for support from an interpreter. Thematic analysis identified three themes related to difficulties with pain assessment: contrasting approaches, differing perceptions of pain and overcoming challenges.

CONCLUSIONS

The reduced ability to communicate between child, parent and healthcare professional highlights the need to identify forms of assessment based on individual cases.

RELEVANCE TO CLINICAL PRACTICE

The number of children with English as an additional language has seen a marked rise over the last decade. In situations where communication ability is reduced, assessment of pain should be tailored to meet the needs of the child. This may require timely access to interpreter services.

Do abused young children feel less pain?

The objective of this study was to investigate whether acute pain in abused children was under recognized by doctors and nurses compared to children evaluated for accidental injuries. We hypothesize that an abused child's reaction to physical pain could be an additional symptom of this challenging diagnosis. For the observational prospective case control study in an emergency department, children were eligible when: younger than six years old, the reported trauma occurred within the previous seven days, the trauma comprised a bone injury or burn, and the child was able to express his or her pain. The case group comprised children for whom the medical team reported their abuse suspicions and supporting information to a court, and whose cases of abuse were subsequently confirmed. The control group consisted of children with a plausible cause for their injury and no obvious signs of abuse. The children were matched according to their age and type of trauma. The pain was assessed by doctors and nurses before analgesic administration using a certified pain scale. Among the 78 included children, pain was significantly less recognized in the abused children vs. the controls (relative risk=0.63; 95% CI: 0.402-0.986; p=0.04). We observed a discrepancy between the nurses' and doctors' scores for the pain assessments (Kappa coefficient=0.59, 95% CI: 0.40-0.77). Our results demonstrate that pain expression in abused children is under recognized by medical staff. They also suggest that abused children may have reduced pain expression after a traumatic event. Paying particular attention to the pain of abused children may also optimize the analgesic treatment.

Intraperitoneal ropivacaine and early postoperative pain and postsurgical outcomes after laparoscopic herniorrhaphy in toddlers: a randomized clinical trial

BACKGROUND

Postoperative pain can cause physiological distress, postoperative complications, and extended lengths of hospitalized stay. In children, management of postoperative pain is still recognized as being inadequate.

OBJECTIVE

The aim of this trial was to investigate the effects of intraperitoneal ropivacaine on postoperative pain, and recovery of bowel function and emetic events after laparoscopic herniorrhaphy in toddlers.

METHODS

Seventy-six children aged from 9 months to 3 years were recruited between August 2013 and June 2014 at Tongji Hospital and randomly assigned into two groups. One group received intraperitoneal ropivacaine right before surgery and the control group received intraperitoneal saline. A standard combined general anesthesia procedure was performed under regular monitoring. Postoperative pain was assessed by the FLACC scale. Postoperative analgesic consumption, time to flatus, time to first stool, and postoperative emetic events were also recorded.

RESULTS

When compared with the control group, children who received intraperitoneal ropivacaine experienced less pain 0-4 h after surgery [P < 0.001, difference in median FLACC (95% CI) for 2 h time point is 2.00 (0.87-3.13), for 4 h time point is 1.00 (0.55-1.45)]. In addition, the number of toddlers who received analgesia 0-24 h after surgery in the ropivacaine group was lower than that in the control group [P < 0.001, difference in proportions (95% CI) is 0.575 (0.3865-0.7638)]. Compared with the control group, time to flatus in ropivacaine group was also much shorter [21.1 h vs 16.7 h, P = 0.04, difference in mean (95% CI) is 4.4 (1.49-7.28)], and the time to first stool after surgery was earlier in the ropivacaine group [30.7 h vs 25.6 h, P = 0.003, difference in mean (95% CI) is 5.1 (1.78-8.45)]. Furthermore, the incidence of emetic events in the ropivacaine group was significantly lower than the control group [32.4% vs 11.1%, P = 0.03, difference in proportions (95% CI) is 0.212 (0.0246-0.4002)].

CONCLUSION

The present results indicate that intraperitoneal ropivacaine reduces early postoperative pain and improves recovery after laparoscopic herniorrhaphy in toddlers. Therefore, IPLA is a good stratagem for postoperative pain management after laparoscopic surgery in toddlers.

Children receive less analgesia in general ERs than adults: A retrospective study

Background/Introduction: Oligoanalgesia is a common phenomenon in the Emergency Department (ED) with children being especially at risk. However, the extent to which pediatric patients are being undertreated for acute pain in relation to their adult counterparts is not well understood, especially in general (i.e., mixed adult and pediatric) EDs. This study was designed to compare the pain medication received by adult and pediatric patients with appendicitis presenting to a general ED. Methods: A retrospective chart review of 165 patients, 92 adult (mean age: 35.7 ± 15.7 years) and 73 pediatric (mean age: 11.0 ± 3.0 years) with a discharge diagnosis of “appendicitis” were included in this study. Demographic information as well as data regarding type, timing, and received amount of pain medication were collected. Adult and pediatric data were then compared using independent t-test or chi-square analysis. Effect sizes were also calculated. Results: Pediatric patients were significantly more likely than adult patients to not receive any analgesia during their ED stay (58.9% vs 20.7%, p>0.001, Cramer's V = 0.39). They were also significantly less likely to receive opioid analgesics, compared to adults (27.4% vs. 71.7%, p>0.001, Cramer's V = 0.44). Finally, mean pain scores recorded at presentation were significantly lower for children vs. adults (6.5 vs 7.2 out of 10, p = 0.015, r = 0.20). Conclusion: In this sample, pediatric patients with appendicitis presenting to a general emergency department received less opioid pain medication, and less pain medication in general, than their adult counterparts.

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments

Objectives

Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation.

Methods

Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman’s Tailored Design method was used to distribute the survey from June to July 2014.

Results

Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition.

Conclusions

Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts.

Pediatric musculoskeletal pain in the emergency department: a medical record review of practice variation

OBJECTIVE

Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to the emergency department (ED). The primary objective of this study was to describe current analgesic administration practices for the outpatient management of children's MSK pain, both in the ED and postdischarge.

METHODS

We reviewed the medical records of consecutive pediatric patients evaluated in either a pediatric or a general ED (Edmonton, Alberta) during four evenly distributed calendar months, with a diagnosis of fracture, dislocation, strain, or sprain of a limb. Abstracted data included demographics, administered analgesics, pain scores, discharge medication advice, and timing of clinical care.

RESULTS

A total of 543 medical records were reviewed (n  =  468 pediatric ED, n  =  75 general ED). Nineteen percent had documented prehospital analgesics, 34% had documented in-ED analgesics, 13% reported procedural sedation, and 24% documented discharge analgesia advice. Of those children receiving analgesics in the ED, 59% (126 of 214) received ibuprofen. Pain scores were recorded for 6% of patients. At discharge, ibuprofen was recommended to 47% and codeine-containing compounds to 21% of children. The average time from triage to first analgesic in the ED was 121 ± 84 minutes.

CONCLUSIONS

Documentation of the assessment and management of children's pain in the ED is poor, and pain management appears to be suboptimal. When provided, ibuprofen is the most common analgesic used for children with MSK pain. Pediatric patients with MSK pain do not receive timely medication, and interventions must be developed to improve the "door to analgesia" time for children in pain.

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.

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.

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.

Robust and Accurate Modeling Approaches for Migraine Per-Patient Prediction from Ambulatory Data

Migraine is one of the most wide-spread neurological disorders, and its medical treatment represents a high percentage of the costs of health systems. In some patients, characteristic symptoms that precede the headache appear. However, they are nonspecific, and their prediction horizon is unknown and pretty variable; hence, these symptoms are almost useless for prediction, and they are not useful to advance the intake of drugs to be effective and neutralize the pain. To solve this problem, this paper sets up a realistic monitoring scenario where hemodynamic variables from real patients are monitored in ambulatory conditions with a wireless body sensor network (WBSN). The acquired data are used to evaluate the predictive capabilities and robustness against noise and failures in sensors of several modeling approaches. The obtained results encourage the development of per-patient models based on state-space models (N4SID) that are capable of providing average forecast windows of 47 min and a low rate of false positives.

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.

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.