Children In Emergency Department Research Articles

Successful Flumazenil Reversal of Paradoxical Reaction to Midazolam in a Child

BackgroundGreater attention to and management of anxiety and pain in pediatric patients signifies a healthy evolution in the care of children in emergency departments (EDs). Interventions to address such distress may involve unanticipated adverse effects. Midazolam, a benzodiazepine commonly administered to children for anxiolysis, may precipitate paradoxical agitation and delirium, a rare but alarming effect that warrants prompt identification and treatment. Case ReportThe case presented is that of a 4-year-old girl who received oral midazolam and developed a paradoxical reaction, which was reversed successfully with flumazenil. This is the first such case report in an ED involving a child. Why Should an Emergency Physician Be Aware of This?Emergency physicians must stay abreast of the adverse and unintended effects of the treatments provided. The literature on benzodiazepine-induced paradoxical reactions is reviewed, and flumazenil as well as other treatment options and anxiolytic alternatives are presented.

Cough and cold medications: Why don't they go away?

At some level, most of us realize that the bulk of “cough and cold medications” don't really work and may be harmful to children. About six years ago, the US Food and Drug Administration and the pharmaceutical industry undertook some initiatives to limit the use of such preparations in young children, those most vulnerable to adverse effects. How well have these initiatives worked? According to a study in the current issue of The Journal, they have not had much of an impact. Using information from administrative databases, Mazer-Amirshahi et al examined prescribing patterns and over-the-counter (OTC) recommendations of these products before and after these initiatives. Although there was some change in the prescription use of these drugs, OTC recommendations were either unchanged or, in the case of older children in ambulatory clinics, actually increased. Although it may be argued (and the authors acknowledge) that sufficient time may not have elapsed for the interventions to have had an impact, this is a sobering reminder that the urge to “do something” for those pesky colds persists, even when that “something” may do more harm than good. Article page 1024▶ The Impact of Pediatric Labeling Changes on Prescribing Patterns of Cough and Cold MedicationsThe Journal of PediatricsVol. 165Issue 5PreviewTo evaluate the impact of initiatives created by the pharmaceutical industry and the Food and Drug Administration to limit the use of over-the-counter (OTC) cough and cold medications (CCMs) in young children in emergency departments (EDs) and ambulatory clinics. Full-Text PDF

Boots on the ground: how to influence your local radiology departments to use appropriate CT dose.

Most pediatric CT examinations (as many as 85%) are performed at non-pediatric-focused facilities. In contrast to children's hospitals and pediatric emergency departments, the number of CT examinations is increasing at these non-pediatric facilities. Compliance with diagnostic reference levels (DRLs) for dose has been shown to be poor at several metropolitan centers. Several high-yield interventions are worth exploring in an effort to achieve more optimal imaging care of children, such as electronic transfer of images to prevent duplication of examinations as well as personal feedback to referring institutions on dose, indications and quality by the pediatric referral center.

Bacteremia in previously healthy children in Emergency Departments: clinical and microbiological characteristics and outcome

A blood culture (BC) is frequently requested in both patients with a suspected occult bacteremia/invasive infection as well as those with certain focal infections. Few data are available on the characteristics of patients in whom a bacteremia is identified in the Pediatric Emergency Department (PED). A prospective multicenter registry was established by the Spanish Pediatric Emergency Society. Epidemiological data, complementary test results, clinical management, and final outcome were recorded. Data from the first three years of the registry were analyzed. A true bacterial pathogen grew in 932 of 65,169 BCs collected [1.43%; 95 % confidence interval (CI) 1.34-1.51%], with 711 of them collected in patients without previously known bacteremia risk factors. Among them, 335 (47.1%) were younger than 1 year old and 467 (65.7%) had a normal Pediatric Assessment Triangle (PAT) on admission. Overall, the most frequently isolated bacterial species was Streptococcus pneumoniae (27.3%; 47.6% among patients with an altered PAT). The main pathogens were Escherichia coli (40.3%) and S. agalactiae (35.7%) among patients younger than 3months, S. pneumoniae among patients 3-60months old (40.0%), and S. aureus (31.9%) among patients over 60months of age. Neisseria meningitidis was the leading cause of sepsis in patients older than 3months. Eight patients died; none of them had a pneumococcal bacteremia and all had abnormal PAT findings on admission. S. pneumoniae is the main cause of bacteremia in patients without bacteremia risk factors who attended Spanish PEDs. Age and general appearance influence the frequency of each bacterial species. General appearance also influences the associated mortality.

Student voice - Reflecting on experience.

MY RECENT work in the children's emergency department has brought to light how worrying it is for parents when their child is admitted to hospital.

The Impact of Pediatric Labeling Changes on Prescribing Patterns of Cough and Cold Medications

To evaluate the impact of initiatives created by the pharmaceutical industry and the Food and Drug Administration to limit the use of over-the-counter (OTC) cough and cold medications (CCMs) in young children in emergency departments (EDs) and ambulatory clinics. Analysis of the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey was performed comparing 2005-2006 and 2009-2010 in children aged ≤ 12 years with a reason for visit consistent with cough or cold-related symptoms. Data were stratified by age (<2 years, 2-6 years, and 6-12 years). Descriptive frequencies and survey-weighted χ(2) tests were used to assess OTC and prescription CCM prescription rates in ED and ambulatory clinic settings. Comparing 2005-2006 and 2009-2010 revealed no changes in ED use of OTC CCMs; however, the use of prescription CCMs decreased, from 6.7% to 2.9% (P = .001). In ambulatory clinics, the overall rate of OTC CCM use increased from 6.3% to 11.1% (P = .001); however, use by children aged <2 years was unchanged. Prescription CCM use in EDs declined in all age groups, but in ambulatory clinics, decreases were significant only in patients aged <2 years. Implementation of pharmaceutical industry and Food and Drug Administration initiatives did not decrease the use of OTC CCMs in children aged <2 years in EDs or ambulatory clinics. The use of prescription CCMs was decreased in both settings, however.

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

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

Variation in treatment of acute childhood wheeze in emergency departments of the United Kingdom and Ireland: an international survey of clinician practice

ObjectiveNational clinical guidelines for childhood wheeze exist, yet despite being one of the most common reasons for childhood emergency department (ED) attendance, significant variation in practice occurs in other settings....

Observational study of family member presence for pediatric emergency department procedures.

The aim of this study was to observe the proportion of family members who choose to remain present during children's pediatric emergency department procedures in actual clinical situations. Family members of a convenience sample of children undergoing invasive procedures in a pediatric emergency department were observed. Data were collected on whether family members chose to remain present or leave during the procedure and family member and health care worker behaviors. Consent to participate in the study was obtained after the observation, and family members were surveyed regarding demographics, anxiety, and previous experiences. Fifty-nine children undergoing 66 procedures and accompanied by 83 family members were enrolled. The median age of the children was 69 months; 47% were female and 73% were Hispanic. The family members consisted of 64% mothers and 24% fathers, with a median age of 33 years. The most common procedures were vascular access (25), laceration repair (11), and urethral catheterization (9). Overall, 73% of the family members stayed during the child's procedure, 18% left, and 9% showed some mixture of staying and leaving. Health care workers asked the family members to leave twice, encouraged them to leave once, and used nonverbal cues to exclude the family members twice. Caregivers helped to restrain the child 35% of the time. Family members remain present during actual children's emergency department procedures less often than they indicate they would in hypothetical scenario surveys.

Mother Approaches to Children with Fever

Objective: Fever, one of the most common symptoms of childhood, is a complaint that the families worried about the most. The families want to know its reason, and it constitutes a significant part of visits to emergency department. In this study, it has been aimed to investigate the knowledge, attitude, antipyretic drug status of the families who bring their children with the complaint of fever, the doses of antipyretic drug and the factors affecting them. Methods : The mothers of 300 children without known chronic disease, who were brought to the Children's Emergency Department of our hospital with complaints of fever between 1-31 March and between the hours of 08:00 to 16:00 and who agreed to complete a questionnaire, were included in the study. Results: One hundred and twenty-seven (42.3%), 173 (57.7%) and 52% of 300 patients enrolled in the study were female, male and under the age of three, respectively. It has been determined that 96% of mothers thought that fever was harmful to children and the cause of the most common fear due to fever for 95% of them was the risk of febrile convulsion. As the level of education of mothers was increasing, the rate of measuring the temperature at home was found to be higher (p = 0.01). It has been observed that more than half of the mothers measured the temperature once an hour, but the frequency of temperature measurement was independent of mothers' education level (p = 0.76). It has been determined that the statistical rate of giving antipyretic with the recommendation of a doctor significantly increased as the maternal education level decreased (p < 0.01). The rate of usingantibiotics without a doctor's recommendation was significantly higher in mothers having sons than mothers having daughters (p = 0.02). Conclusion: It has been determined that the fear of fever was common in mothers; this concern has negatively affected the state of children with fever, increased unnecessary visits and unnecessary treatments of the emergency department. Health workers should inform the mothers one to one about fever during hospital admission in order to rectify this situation caused by the mothers’ lack of knowledge. In addition, the fear of mothers about fever may be reduced by using the mass media with the help of health education programs, which will be organized, by reaching more people and this contributes to the prevention of erroneous procedures. However, more studies are needed to be conducted on how all of these information and training should be done and the effectiveness of these initiatives.

ABSTRACT 774

Background and aims: Prior to 2010, x-rays in emergency department at our hospital were authorized by any doctor at all levels of education. In mid 2010, we introduced a protocol that all x-rays for children in emergency department should be authorized by the consultant during working hours and at night by the seniormost doctor who is usually a registrar. Aims: Primary objective of the protocol was to reduce unnecessary x-rays in children. Secondary aims were to encourage academic discussion early on in the management of sick children and not have any harmful effect by reducing the number of x-rays. Methods: We analyzed the data pre and post introduction of protocol for 18 months each way. We have a computerized system of x-ray from ordering to reporting by the radiologist. We also analyzed the data of re-admission for children who were discharged to look for any harmful effects. Results: We reduced the x-rays in children by over 400% with the introduction of the protocol. No child came to any harm. Less than 1% children required x-ray after admission to the hospital. Conclusions: Consultant approved radiological investigations have significant reduction in number of investigations. Academic discussion and benefit of senior opinion are added advantages. economic analysis would prove ahuge savings too with this method. Long term unseen gains like radiation related cancer remain to be seen in future. We recommend that all pediatric radiological investigations should be approved by a consultant or the most senior doctor in the department.

Do obese children experience more severe fractures than nonobese children? A cross-sectional study from a paediatric emergency department.

To determine whether there is an association between childhood obesity and severe extremity fractures. Associations between obesity and complications related to the fracture and/or fracture management were also examined. The present study was a retrospective, cross-sectional study conducted at a tertiary care children's emergency department. Eligible cases for review were children (two to 17 years of age) with an extremity fracture. Severe extremity fractures were defined as those requiring manipulation under anesthesia, open operative repair and/or admission to hospital. The primary outcome was the proportion of severe extremity fractures and the secondary outcome was the proportion of complications. A total of 1340 charts of children who presented with extremity fracture from January 2008 to December 2010 were reviewed. The mean (± SD) age of the study population was 9.1±4.0 years and 62.1% were male. Overall, 19.9% (95% CI 17.8% to 22.0%) were obese and 39.6% (95% CI 36.7% to 39.1%) sustained a severe extremity fracture. The OR of severe extremity fractures among obese versus nonobese children was 1.00 (95% CI 0.76 to 1.32), adjusted for age, sex and mechanism of injury. In addition, the OR of experiencing complications among obese relative to nonobese children was 1.12 (95% CI 0.68 to 1.85). The results of the present study demonstrated that in children with extremity fractures, obese children were not at increased risk for sustaining more severe extremity fractures or subsequent complications compared with nonobese children.

G207(P) FP10 prescribing in a Children's Emergency Department

<h3>Aims</h3> FP10s are routinely used for children requiring urgent medication on discharge home from the emergency department. FP10s are legal documents requiring specific patient, prescriber and medication data for dispensing by a pharmacist. There is a cost associated with this, which is not regulated if certain unlicensed concentrations are used; our department had previously incurred a cost of £2000 for liquid ranitidine. We aim to audit the quality of FP10 prescribing and type of medications prescribed in a South London Children’s ED. <h3>Methods</h3> A retrospective analysis of a random selection of 150 FP10s issued over the preceding 6 month period. We used guidance from BNFc and London Deanery as the standard for legal requirements and good practice prescribing. <h3>Results</h3> 150 prescriptions were analysed. 39 different medication groups were prescribed; the commonest being antibiotics, asthma medications and analgesics. All prescriptions were legible and included patient name, DOB and prescriber signature. Patient age, address, date of prescription and name of prescriber were included in at least 97% of our sample. GMC number was included in only 27% of FP10s. The majority of medications were prescribed by their generic name and a dose provided (87%, 87%). However, only 45% included a route of administration, 61% included the formulation required and 19% included a concentration of a liquid medication. 3% of FP10s specified a weight with no prescriptions indicating a dose/kg. 2 prescriptions gave a dose in micrograms, however both were incorrectly abbreviated to ‘mcg’. No sugar-free preparations were prescribed. 71% of patients had allergy status appropriately documented. <h3>Conclusion</h3> We must ensure that FP10 prescribing is legally correct and cost effective. We have introduced specific FP10 teaching during induction. A poster highlighting required information with ‘model’ FP10s has been placed at point of use. Doctor name stamps are being encouraged. Re-audit following these changes will be performed. Electronic prescribing would improve FP10 prescribing. Dispensing costs can be reduced through specific prescribing and pre-pack dispensing of the most commonly prescribed medications. Implementing these changes could potentially save our department up to £10K per year.

P03 Clinician variation in treating childhood wheeze in Emergency Departments of the United Kingdom AND Ireland – an international survey

AimsNational clinical guidelines for childhood wheeze have existed for several years. Despite being one of the commonest reasons for childhood Emergency Department (ED) attendance, significant variation in practice has been...

MP26-13 PREDICTORS OF CT UTILIZATION IN THE EMERGENCY DEPARTMENT FOR CHILDREN WITH NEPHROLITHIASIS

You have accessJournal of UrologyPediatrics: Testis, Varicocele & Stones1 Apr 2014MP26-13 PREDICTORS OF CT UTILIZATION IN THE EMERGENCY DEPARTMENT FOR CHILDREN WITH NEPHROLITHIASIS Justin Ziemba, Douglas Canning, Jane Lavelle, and Gregory Tasian Justin ZiembaJustin Ziemba More articles by this author , Douglas CanningDouglas Canning More articles by this author , Jane LavelleJane Lavelle More articles by this author , and Gregory TasianGregory Tasian More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.901AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For children with suspected nephrolithiasis, the AUA recommends ultrasound (US) as the initial imaging modality with CT reserved if US is non-diagnostic. We sought to identify factors influencing initial CT utilization for children who presented to the Emergency Department (ED) with nephrolithiasis. METHODS We performed a cross-sectional study of children ≤18 years with nephrolithiasis who presented to the ED of our children′s hospital or an outside hospital (OSH) within our referral network between 2004 and 2012. The outcome was use of CT as the initial diagnostic test in the ED. Predictor variables included patient demographics and hospital characteristics, which were obtained via an electronic survey sent to referring OSH EDs (Table 1). Variables significantly associated with CT utilization on univariate analysis were included in a hierarchical multivariate logistic regression model controlling for hospital type (e.g. children versus non-children's hospital) to estimate the association between patient and hospital characteristics and CT utilization. RESULTS 539 children who presented to 110 different hospitals were included. There were no demographic differences between the 217 children who presented to our hospital and the 322 who originally presented to an OSH. On multivariate analysis, older age (OR 1.09; 95% CI 1.03-1.15) was associated with higher CT utilization. A more recent year of presentation (OR 0.79; 95% CI 0.72-0.87) and the presence of a clinical pathway where US is the initial diagnostic test for the evaluation of suspected nephrolithiasis (OR 0.01; 95% CI 0.00-0.45) were significantly associated with decreased CT utilization (Table 2). CONCLUSIONS The presence of a clinical pathway in which US is the initial diagnostic test for the evaluation of suspected nephrolithiasis was associated with decreased CT utilization. Implementation of care pathways may lead to lower radiation exposure and better adherence to AUA guidelines. Table 2. Adjusted Odds Ratios for the Association Between Patient and Hospital Characteristics and CT Utilization in the ED OR 95% CI p-Value Age at Diagnosis (years) 1.09 1.03-1.15 0.002 Gender 1.07 0.61-1.89 0.793 Year of Diagnosis 0.79 0.72-0.87 <0.001 Pediatric ED Size (no. beds) 0.72 0.04-11.54 0.815 Pediatric ED Volume (visits/year) 2.26 0.80-6.39 0.124 US Availability (24 hrs/day) 0.20 0.00-37.50 0.544 CT Availability (24 hrs/day) 0.58 0.00-111.73 0.839 Stone Algorithm (Present) 0.01 0.00-0.45 0.017 OR=odds ratio; CI=confidence interval Table 1. Survey Responses from Referring Emergency Departments Question Response Rate (n=14) Time To Hospital (%) ≤30 Min 5 (36) >30 Min 9 (64) Practice Location (%) Suburban 11 (79) Urban 3 (21) Practice Environment (%) Academic 5 (36) Non-Academic 9 (64) Children's Hospital Affiliate (%) Yes 5 (36) No 9 (64) Trauma Center (%) Yes 2 (14) No 12 (86) Total Emergency Room Beds (%) ≤30 9 (64) >30 5 (36) Dedicated Pediatric Emergency Room (%) Yes 5 (36) No 9 (64) Total Pediatric Emergency Room Beds† (%) ≤5 2 (40) >5 3 (60) General Pediatrician Available for Consultation (%) Yes 11 (79) No 3 (21) Urologist Available for Consultation (%) Yes 12 (86) No 2 (14) Pediatric Urologist Available for Consultation‡ (%) Yes 1 (8) No 11 (92) CT Scanner in the Emergency Room (%) Yes 11 (79) No 3 (21) Ultrasound Available (%) Yes 14 (100) No 0 (0) Ultrasound Available 24 Hours per Day (%) Yes 11 (79) No 3 (21) Radiologist Reads Emergency Room Films (%) Yes 13 (93) No 1 (7) Radiologist Available 24 Hours per Day‡ (%) Yes 6 (50) No 6 (50) Annual Patients Evaluated in Emergency Room (%) ≤50,000 8 (57) >50,000 6 (43) Annual Pediatric Patients Evaluated in Emergency Room (%) ≤10,000 7 (50) >10,000 7 (50) Clinical Pathway for Evaluation of Suspected Nephrolithiasis (%) Yes 1 (7) No 13 (93) † Only includes respondents with a dedicated pediatric emergency room ‡ Only 12 respondents © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e256 Peer Review Report Advertisement Copyright & Permissions© 2014MetricsAuthor Information Justin Ziemba More articles by this author Douglas Canning More articles by this author Jane Lavelle More articles by this author Gregory Tasian More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Paediatric head injuries treated in a children's emergency department from Cluj-Napoca, Romania

The aim of the study was to describe paediatric head injuries and identify factors that led to advanced care. Incident cases of head injuries that sought care from December 2008 to October 2010 at Children's Emergency Hospital Cluj-Napoca were evaluated. The main outcome was transfer or admission to advanced care. From a total of 3053 children treated for an injury, 1541 (50.4%) presented with head injury. A total of 960 (62.3%) of the children with a head injury required advanced care treatment. Young children were more likely to suffer a head injury than older children, but a higher proportion of older children required advanced care (70.3%). Children who suffered a head injury as a consequence of road traffic were almost five times more likely to require advanced care (OR: 4.97; 3.09-8.06) than being released. Our results suggest that data on injuries provide evidence-based information on the nature of injuries children are prone to, and what activity, type, and mechanism of injury impact Romanian children.

Impact of a GP-led walk-in centre on NHS emergency departments

ObjectiveTo determine the impact of the GP-led walk-in centre (WIC) in Sheffield (England) on the demand for emergency department (ED) care.MethodsA survey of patients visiting the Sheffield GP WIC was...

Variability in Discharge Instructions and Activity Restrictions for Patients in a Children’s ED Postconcussion

The objective of this study was to describe discharge instructions given to school-aged patients evaluated in a children's emergency department (ED) following concussion. This was a retrospective cohort study of children 6 to 18 years evaluated in a dedicated children's ED at a level I trauma center in 2008 following acute head trauma regardless of mechanism, identified by any of 27 International Classification of Disease, Ninth Revision diagnoses for head injury, concussion, or skull fracture. Included were those presentations consistent with the Zurich definition for concussion. Excluded were hospital admission, death before admission, evidence of intoxication, or structural abnormality on imaging. Univariate and multivariate analyses determined adjusted odds ratios (ORs) for receipt of concussion-specific discharge instructions and activity restrictions. Of 350 eligible patients, the 218 included patients were mostly male (68%) with mean age 12.8 (SD, 3.4) years. Injury characteristics included sports-related, 42%; fall, 23%; loss of consciousness, 33%; headache, 75%; dizziness, 29%; amnesia, 25%; and vomiting, 19%. Most patients underwent imaging (81%). Discharge characteristics included concussion stated in final diagnosis, 31%; concussion-specific instructions, 62%; and activity restrictions, 34%. Concussion-specific discharge instructions were more likely for loss of consciousness (OR, 1.7; 95% confidence interval [CI], 1.22-2.36), and activity restrictions were more likely for sport-related injury (OR, 1.31; 95% CI, 1.02-1.76) and amnesia (OR, 1.42; 95% CI, 1.01-1.98). Most children meeting diagnostic criteria for concussion were discharged without concussion-specific diagnoses or activity restrictions. Given the risks associated with untimely return to both physical and cognitive activity after concussion, improved awareness and standardization of disposition are imperative for the management of these young patients in the ED.

Establishing consistency and best practice in the care of children and adolescents with eating disorders: developments at the Mater Children's Hospital (MCH) and Mater Child and Youth Mental Health Service (CYMHS)

One of the biggest challenges for an organisation and for clinicians and practitioners is implementing a new program or a new practice. Following an 18 month research project and the recruitment of an Eating Disorders Coordinator the MCH and Mater CYMHS have developed and implemented a number of protocols across its service to ensure consistency in the continuum of care and to ensure that treatment is in line with the best current evidence base. Within the campus based services these have included; • Development of a protocol for the CYMHS Inpatient Unit to provide structure and consistency to the admission of patients with restrictive eating disorders. • Design and roll out of a Care Pathway for the Paediatric Medical Ward where medical crises associated with malnutrition are managed. • Guidelines for triage of such patients in the Children's Emergency Department with parameters indicative of further consultation and/or admission. • Off campus/outpatient service development has included; • The implementation of Maudsley Family Based Therapy as the model of choice giving structure and consistency to outpatient treatment. • Guidelines for community staff for medical monitoring nutritionally compromised children and adolescents. This presentation will refer to implementation science as a framework to describe the process and stages of development involved in the implementation of these projects. This abstract was presented in the Children and Youth Treatment and Service Development stream of the 2013 ANZAED Conference.

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

BackgroundPain 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.MethodsA 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.ResultsRoutine 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.ConclusionsDespite 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.