Discussion
We have described the structures relating to paediatric pain management across an international paediatric emergency network, and identified significant variations contributing to processes and outcomes in paediatric pain management.10 Variations included guideline availability and content, staff education, pain reassessment, pain scale usage, pharmacological accessibility, PGD usage and procedural sedation availability. Variation existed in non-pharmacological approaches, including distraction amenities, parental empowerment and access to play services.
The aim of timely, efficient and adequate pain management is not being achieved in EDs despite multiple sequential audits, with deterioration in timeliness of treatment being demonstrated in the most recent national audit of patients with moderate and severe pain.8 A recent UK study identified that other ED tasks were prioritised over pain management if this was not aligned with department core priorities, and not perceived as a key organisational priority for which staff were held accountable.13 When recommending interventions one must consider a hierarchy of effectiveness, and each solution’s level of feasibility. A systematic review and narrative synthesis of ED interventions to improve pain management revealed it was impossible to estimate effectiveness of interventions, or identify which had the greatest impact.14 A hierarchy of intervention effectiveness in EDs has been described, with forcing functions having highest effectiveness, and education or personal initiative/vigilance having the lowest.15 Medication safety literature demonstrates system based interventions are the most effective, with highest leverage, but are the least feasible; conversely, person-based interventions are least-effective, with lowest leverage, but are most feasible.16
Results demonstrated that 1/4 of paediatric hospitals and trauma centres, and 1/3 of hospitals with an annual paediatric ED attendance over 50 000, did not have local guidance to support best practice in paediatric pain management. In previous studies, introducing pain protocols and education in EDs have improved analgesia provision, including usage of intravenous analgesia.17 National guidance4 and standards6 which promote optimised pain assessment and management need to be implemented uniformly, as failure to do so commonly leads to oligoanalgesia.18 In EDs, this should be interdisciplinary, with clear lines of responsibility for achieving and measuring pain control. Multimodal pain management strategies are needed to minimise pain and discomfort that incorporate a combination of pain control strategies, such as opioids, non-steroidal anti-inflammatory drugs and non-pharmacological interventions.19 The uniform implementation of a single national guideline is a potentially moderately effective intervention, through simplification and standardisation of pain management across the health system.
Education varied in content, availability and strategy across sites. Under half delivered formal professional training in pain management, or mandated pain/analgesia competencies, implying that pain education is a low priority for over 50% of responding sites. Education and training are essential in enabling effective pain management,18 and knowledge acquisition through mandated training could be targeted at a national or network level. This intervention is likely moderately effective, and highly feasible, especially if delivered from post-graduate training institutions. To optimise the feasibility of such a strategy, it is essential to simplify practices and content. For example, ten different pain scales were in use, a factor which is a potential threat to any national training package given the lack of translation between institutions. Simplifying by reducing the volume, and standardising pain tool usage, is a medium leverage and moderately effective intervention. Coupling these strategies align well with existing literature, as previous evidence-based knowledge translation interventions demonstrates sustained improvement in paediatric pain practices.20
Assessment and reassessment of pain are central to optimising pain management, but given current constraints on healthcare systems, reassessment of any condition or symptom in stable patients, including pain, is often the most challenging element of care. Pain is reassessed in only 15% of ED patients nationally.8 There is significant positive association between documentation of a pain score and subsequent use of any analgesic,21 and the converse is also true.18 One moderate to highly effective system-based intervention is alerts using the electronic triggers in ED information systems for pain reassessment. Using technology to engage parents in acute pain care, including reassessment, may improve the child’s experience, increase parental satisfaction and reduce anxiety.22
A large difference in the quantities of non-pharmacological analgesia resources across sites existed. Level 1 evidence from systematic reviews/meta-analysis of relevant randomised trials demonstrated that non-pharmacological analgesia reduces pain,3 and Intercollegiate guidelines therefore state all EDs that treat children should employ a play specialist.7 This method of pain control is often overlooked, and sites should prioritise incorporating this as a priority. The forcing function of mandating such an intervention is most effective in achieving a successful change and may not be a huge burden when one considers the cost and availability of smart devices.
Local accessibility to medications, practices, and attitudes effect optimal practice.18 There was widespread access to intranasal opioids and nitrous oxide/Entonox. Intranasal opioids have gained increased popularity over intravenous opioids due to their fast onset, safety and ease of administration.23 RCEM guidelines advocate diclofenac sodium, codeine or oral morphine for moderate pain.4 Since 2013, this has become more limited as codeine is contraindicated in children under 12 years due to the risk of toxicity.24 Morphine can require incremental dosing with frequent pain reassessment to achieve optimal analgesia due to the risk of respiratory depression. Barriers to the routine use of morphine include opiophobia and monitoring requirements.24 Intranasal fentanyl is equivalent to intravenous/intramuscular morphine in reducing pain associated with acute paediatric fracture in the ED and internal evidence where it was incorporated into a triage protocol demonstrated earlier onset analgesia compared with intravenous opioids.3 We suggest bodies producing national guidance include drugs suitable for intranasal administration for moderate to severe pain. Other alternatives including inhaled methoxyflurane3 may become future additions following completion of randomised controlled trials.
Modifying organisational infrastructure to remove barriers is crucial. The universal implementation of PGDs could yield a moderately effective solution. These enable administration of specified prescription-only medicines to groups of patients under an overarching prescription, removing the need for individual-level prescription every time, with consequent reductions in time to analgesia.25 Single-checked PGDs are used successfully in many paediatric EDs without increasing rates of medication errors.25 Broadening their use and incorporating nurse-led protocols are likely to reduce time to analgesia and improve pain assessment.21
We have described current pain management structures in paediatric emergency care at a network level, and provided an insight into acute paediatric pain management. Variation is high, which likely contributes to poor pain outcomes identified in national audits. We, therefore, recommend person-centred and whole system interventions, of varying effectiveness, addressing these structural variations, to improve pain outcomes for children attending EDs which are summarised in box 1.
Box 1Suggested Solutions (with effectiveness and feasibility) to improve paediatric pain management in emergency department (ED)
Reprioritise paediatric pain management as a core principle in each ED aiming to reduce patient distress through pharmacological and non-pharmacological interventions (least effective, most feasible).
Integration of mandated pain assessment and reassessments using electronic triggers in an ED information system (moderately to highly effective, moderately to highly feasible).
Simplification and standardisation of pain management to support best practice including a concise number of pain scales (moderately effective, highly feasible).
Choice of medications available, route of administration and consideration of the intranasal route for moderate pain (moderately effective, moderately feasible).
Incorporate training on acute pain management at induction and developing pain management competencies (least effective, highly feasible).
Expand the number of medications available through patient group directions (PGDs) and single check PGDs (moderately effective, highly feasible).
Expand access to play specialist services and non-pharmacological interventions (uncertain effectiveness and feasibility).
Empower patients/parents to request analgesia (least effective, most feasible).
Expand access to paediatric procedural sedation for all sites (moderately effective, least feasible).
Regular local audits of pain management to monitor practices and highlight areas for improvement with frontline staff. (least effective, most feasible).