Pediatric Pain Management Innovations: Recent Advancements in Pain Management Techniques for Pediatric Patients in the Emergency Department: A Narrative Review

Clinical Policy: Critical Issues in the Sedation of Pediatric Patients in the Emergency Department

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Factors affecting and strategies to improve pain management in emergency departments: a comprehensive systematic review.

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Pain in children remains an unsolved problem.

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

Investigating Rare Events and a Discussion on Waiting Room Chest Pain Evaluations: Answers to the November 2010 Journal Club Questions

Pain is a component of up to 80% of all emergency department (ED) visits. Oligoanalgesia, the under-treatment of pain, is a recognized problem in the ED and can have numerous detrimental effects for the pediatric patient. Surveying emergency medicine residents, our primary objectives were to describe a) the extent and type of training received in pediatric acute pain management, b) their management approach to common painful pediatric presentations, c) their level of comfort in assessing and treating acute pain, d) their perceived facilitators and barriers to optimally managing pain, and e) their attitudes towards managing such pain in the ED. A descriptive, cross-sectional survey was administered to all Royal College Emergency Medicine (EM) and Pediatric Emergency Medicine (PEM) residents, the Canadian College of Family Physician's EM residents, Clinical Fellows and PEM Fellows at three Canadian universities. A novel survey tool was created and distributed from May to June 2013. Surveys were completed online, using a modified Dillman approach. Our response rate was 46% (56 of 122). Forty-five percent (25 of 55) of residents had not received any training for pediatric pain assessment. All years of residents were uncomfortable with the assessment of pain in 0- to 2-year-olds (P=0.07). For patients aged two to 12 years, level of comfort with pain assessment increased with years of training (P=0.02). When assessing pain in children with disabilities, 83% (45 of 54) of residents were ‘extremely’ or ‘somewhat’ uncomfortable; 65% (47 of 55) of residents had not received any training on how to assess pain for such patients. Sixty-nine percent (38 of 55) of residents had received training on how to treat pediatric pain. All residents were more comfortable using pain medication for a nine-year-old, as compared to a one-year-old (oral oxycodone P=0.00003, oral morphine P=0.00002, IV morphine P=0.004). Ninety-eight percent (54 of 55) of residents felt that it was ‘extremely’ or ‘somewhat’ important to receive education about pediatric pain management. Their preferred methods to learn children's pain management were through role modeling (61%) and lectures (57%). Top challenges to optimal pediatric pain management were non-verbal patients, patients with disabilities, and young infants. Pediatric pain management education is important to EM residents. Residents recall receiving sub-optimal training on this important topic. They are especially uneasy in the management of younger children and those with disabilities. This study's findings can be used to inform post-graduate curriculum planning, in order to optimize pediatric pain assessment and treatment education.

Emergency medicine and pain: A topography of influence

Objectives Managing pain in children presenting to hospital should be a high priority for staff in the emergency department (ED) and on the children’s ward. Many factors influence the quality of this provision. Following an audit of pain management in children with fractures, the Royal College of Emergency Medicine (RCEM) identified potential improvements in the care of children presenting to District General Hospitals having sustained a fracture. As part of a department wide focus on pain management and closer links being forged between paediatrics and ED, this project aimed to assess staff confidence in paediatric pain management as well as patient experiences in ED and on the paediatric ward. Methods An electronic survey, alongside face-to-face discussion, was used to ascertain staff confidence levels, prior training and potential ideas for innovation in paediatric pain management. Alongside this a paper survey was sent to 50 families whose children were either seen in ED or admitted to the ward with a fracture. The feedback was analysed in a focus group involving medical and play specialist staff. We plotted the course of the patient journey constructing a driver diagram. Results The primary drivers included medicines provision, training and ability and a reassessment process. This culminated in change ideas such as: access to a distraction box in ED, increased awareness of play specialist availability, formal training in both departments and the development of a pain pathway tool. Conclusion Amongst other systems changes and wider education advances an acute paediatric pain tool was developed. This tool has been designed to be used initially at triage and then throughout an admission. The tool includes pain scores and guidance on pain management depending on the score and injury pattern. This tool has been reviewed at the paediatric clinical governance meeting and we are exploring its introduction aiming to evaluate the effect of the tool on staff confidence and patient experience after six months.

Introduction: Effective implementation of an evidence based pain policy for children is affected by nurses' knowledge of, attitudes towards and selfefficacy. Since nurses from different departments and with different levels of education manage pain in children, we evaluated the impact of the nursing ward and educational level on the management of paediatric pain. Methods: Nurses working in paediatric wards or emergency departments of 16 regional or academic hospitals in Flanders, Belgium were invited to participate. A validated multiple choice questionnaire (Pediatric Nurses' Knowlegde and Attitudes regarding Pain Survey, PNKAS) [1] was used to assess knowledge and attitudes while selfefficacy for paediatric pain was assessed based on the Nurses Self Efficacy in Managing Children's Pain questionnaire [2]. Results: Questionnaires from 550 nurses were collected. Deficits in knowledge, attitudes and self-efficacy of nurses were documented. Nurses' knowledge deficits are mainly situated within the area of drug prescription. Compared to nurses from emergency department, nurses from pediatric wards have significantly higher scores on self-efficacy, but not on knowledge and attitudes. As for knowledge and attitudes, nurses with an educational level higher than bachelor score better than nurses with a lower level of education. However, this is not the case as far as self-efficacy is concerned. Conclusions: Nursing ward and educational level influence nurses' management of paediatric pain. This should be taken in consideration during teaching and subsequent implementation of an evidence based paediatic pain policy.[1] Mannworren et al, Pediatr Nurs 2000[2] Chiang et al, J Pain Sympt Manag 2006.

Under-treatment of children's pain in the emergency department (ED) can have many detrimental effects. Emergency medicine (EM) residents often manage pediatric pain, but their educational needs and perspectives have not been studied. A novel online survey was administered from May to June 2013 to 122 EM residents at three Canadian universities using a modified Dillman methodology. The survey instrument captured information on training received in pediatric acute pain management, approach to common painful presentations, level of comfort, perceived facilitators, and barriers and attitudes towards pediatric pain. 56 residents participated (46%), 25 of whom (45%) indicated they had not received any training in pediatric pain assessment. All levels of residents reported they were uncomfortable with pain assessment in 0-2 year olds (p=0.07); level of comfort with assessment increased with years of training for patients aged 2-12 years (p=0.02). When assessing children with disabilities, 83% of respondents (45/54) indicated they were 'extremely' or 'somewhat' uncomfortable. Sixty-nine percent (38/55) had received training on how to treat pediatric pain. All residents reported they were more comfortable using pain medication for a 9 year old, as compared to a 1 year old (oral oxycodone p<0.001, oral morphine p<0.001, IV morphine p=0.004). The preferred methods to learn about children's pain management were role-modeling (61%) and lectures (57%). The top challenges in pain management were with non-verbal, younger, or developmentally delayed patients. Canadian EM residents report receiving inadequate training in pediatric pain management, and are particularly uneasy with younger or developmentally disabled children. Post-graduate curricula should be adjusted to correct these self-identified weaknesses in children's pain management.

Review Objective: To identify the best available evidence on age-friendly nursing interventions used in the management of older people (over 65) during their stay in the Emergency Department Review Questions: 1. What is the effectiveness of age-friendly nursing interventions used in the management of older people (over 65) during their stay in the Emergency Department? 2. What are the recommended policies regarding age-friendly nursing interventions for the management of older people (over 65) during their stay in the Emergency Department? Inclusion criteria: Types of participants: This review will consider men and women over the age of 65 presenting to the Emergency Department. Types of intervention(s)/phenomena of interest: The review will consider any age-friendly nursing interventions in the management of older patients during their stay in the Emergency Department. These may include nursing interventions to enhance comfort, nutrition, hydration, pressure area care, pain management and communication. The opinion part of the review will consider the policies and recommendations related to age-friendly nursing interventions. Types of outcomes: Outcomes of interest for the quantitative part of the review are: pressure area status, hydration status, nutritional status and pain status measured during their stay in the emergency department. The text and opinion part of the review will focus on the recommended policies for age-friendly nursing interventions.

To evaluate statewide emergency department assessment and management of pain in pediatric patients as a quality improvement initiative. 2002 Survey of Illinois Hospital emergency department's pediatric pain assessment and management strategies, in conjunction with a retrospective chart review of children, ages 0 to 15 years, treated for an extremity fracture. Survey results were available for 123 (59.4%) hospitals; 933 charts (107 hospitals) were reviewed for pain management. Survey results were compared with practices identified by chart review. Use of a pain assessment scale estimated by the survey was 92%, compared with 59% use by chart review. Use of pain assessment scales for infants was limited. Fifty percent of patients in moderate to severe pain would be offered an analgesic. Six- to 15-year-old children would be offered opioids more often than children aged 0 to 1 and 2 to 5 years. Offering higher potency narcotic analgesics was associated with patient's age, geographic location of the facility, and emergency department volume. Providing an analgesic (odds ratio 4.53, 95% confidence interval 2.89-7.10), offering supportive care (odds ratio 2.37, 95% confidence interval 1.44-3.89), and pediatric-focused annual nurse competencies (odds ratio 1.90, 95% confidence interval 1.18-3.06) correlated with reduction of the patient's pain. Disparity exists between perceived and documented emergency department pain management practices for children. Quality improvement initiatives should focus on improving pain assessment in infants, treating moderate to severe pain in children of all age groups, and education of health care providers in pain management strategies. Resources should target health care processes effective in decreasing pediatric pain.

We aimed to investigate whether there was an unmet need for paediatric procedural pain management and/or sedation in Danish emergency departments (EDs). Cross-sectional survey of the 21 emergency hospitals in Denmark. Physical restraint during painful procedures was used by 80% (n = 12) of the departments and procedural sedation in children was used in 33% (n = 5) of the EDs. A total of 73% (n = 11) of the participants reported that they believed that there was a need for better pain management and/or sedation of children in their ED. There is an unmet need for paediatric procedural pain management in Scandinavian EDs. Scandinavian guidelines on paediatric pain management and sedation in the ED are needed.