An intervention to improve pain management in the pediatric emergency department.
ABSTRACT The objective of this study was to measure the impact of a structured intervention on pain management in a pediatric emergency department (ED).
Data were prospectively collected from children presenting to an urban tertiary care pediatric ED before and after intervention. Data were collected on the rate and timeliness of analgesic administration, the assessment and reassessment of pain, periprocedural anesthesia, and patient satisfaction. The intervention was developed by a multidisciplinary committee composed of physicians, nurses, and child life specialists and was focused on correcting deficiencies identified before intervention data collection. It consisted of a policy defining pain, pain-appropriate analgesia, age-appropriate pain assessment, and adequate preprocedural and periprocedural analgesia. Implementation occurred through provider education, organizational changes, and patient empowerment.
One hundred two patients were enrolled during the preintervention period, and 109 were enrolled in the postintervention period. The percentage of patients in pain receiving any analgesic increased from 34% to 50%, an increase of 16% (95% confidence interval [CI], 1%-30%). The median time to medication administration decreased from 97 minutes to 57 minutes, a decrease of 40 minutes (95% CI, -84 to 4 minutes). The percentage of children receiving preprocedural analgesia increased from 10% to 62%, an increase of 52% (95% CI, 12%-74%). Reassessment of pain by physicians increased from 6% to 76%, an increase of 70% (95% CI, 59%-78%).
A structured intervention, tailored to pain management shortcomings commonly found in the pediatric ED, can lead to improvements in the treatment and prevention of pain in childhood emergencies.
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ABSTRACT: Review of emergency department pain management practices demonstrates pain treatment inconsistency and inadequacy that extends across all demographic groups. This inconsistency and inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include (1) a lack of educational emphasis on pain management practices in nursing and medical school curricula and postgraduate training programs; (2) inadequate or nonexistent clinical quality management programs that evaluate pain management; (3) a paucity of rigorous studies of populations with special needs that improve pain management in the emergency department, particularly in geriatric and pediatric patients; (4) clinicians' attitudes toward opioid analgesics that result in inappropriate diagnosis of drug-seeking behavior and inappropriate concern about addiction, even in patients who have obvious acutely painful conditions and request pain relief; (5) inappropriate concerns about the safety of opioids compared with nonsteroidal anti-inflammatory drugs that result in their underuse (opiophobia); (6) unappreciated cultural and sex differences in pain reporting by patients and interpretation of pain reporting by providers; and (7) bias and disbelief of pain reporting according to racial and ethnic stereotyping. This article reviews the literature that describes the prevalence and roots of oligoanalgesia in emergency medicine. It also discusses the regulatory efforts to address the problem and their effect on attitudes within the legal community.Annals of emergency medicine 05/2004; 43(4):494-503. · 4.23 Impact Factor
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ABSTRACT: The Wong-Baker FACES Pain Rating Scale (WBS), used in children to rate pain severity, has been validated outside the emergency department (ED), mostly for chronic pain. The authors validated the WBS in children presenting to the ED with pain by identifying a corresponding mean value of the visual analog scale (VAS) for each face of the WBS and determined the relationship between the WBS and VAS. The hypothesis was that the pain severity ratings on the WBS would be highly correlated (Spearman's rho > 0.80) with those on a VAS. This was a prospective, observational study of children ages 8-17 years with pain presenting to a suburban, academic pediatric ED. Children rated their pain severity on a six-item ordinal faces scale (WBS) from none to worst and a 100-mm VAS from least to most. Analysis of variance (ANOVA) was used to compare mean VAS scores across the six ordinal categories. Spearman's correlation (rho) was used to measure agreement between the continuous and ordinal scales. A total of 120 patients were assessed: the median age was 13 years (interquartile range [IQR] = 10-15 years), 50% were female, 78% were white, and six patients (5%) used a language other than English at home. The most commonly specified locations of pain were extremity (37%), abdomen (19%), and back/neck (11%). The mean VAS increased uniformly across WBS categories in increments of about 17 mm. ANOVA demonstrated significant differences in mean VAS across face groups. Post hoc testing demonstrated that each mean VAS was significantly different from every other mean VAS. Agreement between the WBS and VAS was excellent (rho = 0.90; 95% confidence interval [CI] = 0.86 to 0.93). There was no association between age, sex, or pain location with either pain score. The VAS was found to have an excellent correlation in older children with acute pain in the ED and had a uniformly increasing relationship with WBS. This finding has implications for research on pain management using the WBS as an assessment tool.Academic Emergency Medicine 12/2009; 17(1):50-4. · 1.76 Impact Factor
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ABSTRACT: Using data from one of our randomised trials, we investigated post-hoc whether male neonatal circumcision is associated with a greater pain response to routine vaccination at 4 or 6 months. Pain response during routine vaccination with diphtheria-pertussis-tetanus (DPT) alone or DPT followed by Haemophilus influenzae type b conjugate (HIB) was scored blind. 42 boys received DPT and 18 also received HIB. After DPT, median visual analogue scores by an observer were higher in the circumcised group (40 vs 26 mm, p = 0.03). After HIB, circumcised infants had higher behavioural pain scores (8 vs 6, p = 0.01) and cried longer (53 vs 19 s, p = 0.02). Thus neonatal circumcision may affect pain response several months after the event.The Lancet 03/1995; 345(8945):291-2. · 39.06 Impact Factor