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ORIGINAL ARTICLE

An Intervention to Improve Pain Management in the Pediatric Emergency Department


Daniel J. Corwin, MD,* David O. Kessler, MD, MSc, Marc Auerbach, MD, MSc, Ana Liang, MD, and George Kristinsson, MD||
quate analgesia when compared with adults.10,11 Pain is challenging to objectively assess in the pediatric population, because of communication barriers and similarities between the expression of pain and anxiety in children.12 There also still exists an unfounded hesitance to use proper doses of opioids because of inappropriate fears of adverse effects or addiction in this population.13 Pain exposure can be especially harmful to children. Besides being a psychologically negative experience, exposure to pain has been shown to trigger increased pain responses later in life (hyperalgesia) both via pathways of central memory14Y17 and by an increase in activity of pain sensors peripherally, a phenomenon called up-winding of pain.18,19 Early memories of childhood pain have been shown to lead to fear and avoidance of medical care later in life.20 A 2001 joint statement by the American Academy of Pediatrics and the American Pain Society put out a call to improve pain management, specifically by using appropriate assessment tools and techniques, anticipating painful experiences and intervening accordingly, using a multimodal approach to pain management, involving families, and advocating for pain management in children.21 However, inadequate pain management continues to be a problem, and there is a paucity of studies showing the effects of a structured intervention on improving pain management in the pediatric emergency setting. Other fields have demonstrated improvements in pain management by implementing staff-driven interventions. Wilder-Smith et al22 evaluated their department of anesthesia and showed the lack of written algorithms for opioid analgesia, reassessment of pain scores, formal education of staff, and regular meetings to discuss pain management all contributed to deficiencies. Harmer and Davies23 showed education programs among anesthesiologists could improve postoperative pain. In the adult ED, Yanuka et al24 found that expanding the selection of analgesics, introducing a standard protocol, and education programs of nurses and house staff improved the percentage of patients receiving medication and the time to medication administration. This study aims to measure the impact of a structured intervention on pain management in a pediatric ED. We developed a pain management policy based on preintervention data collection, which confirmed deficiencies common to other EDs, including inadequate timeliness and efficacy of analgesic administration, inappropriate use of assessment tools, ignorance toward preprocedural and periprocedural anesthesia, and lack of reassessment of pain. We hypothesize that our policy, tailored to shortcomings commonly found in the pediatric ED, would improve pain management.

Objective: The objective of this study was to measure the impact of


a structured intervention on pain management in a pediatric emergency department (ED). Methods: 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. Results: 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%Y30%). The median time to medication administration decreased from 97 minutes to 57 minutes, a decrease of 40 minutes (95% CI, j84 to 4 minutes). The percentage of children receiving preprocedural analgesia increased from 10% to 62%, an increase of 52% (95% CI, 12%Y74%). Reassessment of pain by physicians increased from 6% to 76%, an increase of 70% (95% CI, 59%Y78%). Conclusions: 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. Key Words: pain management, analgesia, provider training (Pediatr Emer Care 2012;28: 524Y528)

ain is one of the most frequent adverse stimuli experienced in the hospital setting.1,2 Previous studies have shown pain assessment and management to be inadequate and inconsistent in the emergency department (ED).3Y5 Infants and children are an especially vulnerable population regarding both the diagnosis and treatment of pain6Y9 and are more likely to receive inade-

From the *Childrens Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Columbia University Medical Center, New York Presbyterian Morgan Stanley Childrens Hospital, New York, NY; Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Childrens Hospital Oakland, Oakland, CA; and ||Departments of Pediatrics and Emergency Medicine, NYU School of Medicine, New York, NY. Disclosure: The authors declare no conflict of interest. Reprints: Daniel J. Corwin, MD, 2531 Lombard St, Apt 1N, Philadelphia, PA 19146 (e-mail: corwindj@gmail.com). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journals Web site (www.peconline.com). Copyright * 2012 by Lippincott Williams & Wilkins ISSN: 0749-5161

METHODS Data Collection


Data were collected prospectively on a convenience sample in an urban tertiary care pediatric ED during 2 separate 1-month periods, preintervention (July 2008) and postintervention
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Intervention to Improve Pain Management

FIGURE 1. Timeline of study events.

(July 2009). A multidisciplinary committee was formed to develop specific interventions in September 2008. These interventions were implemented in January 2009 (Fig. 1). The ED accepts patients through age 25 years. Verbal informed consent was obtained from all patients followed up before any data collection. Medically unstable patients were not included in this study. Trained research assistants enrolled all patients presenting in pain during separate 6-hour shifts, which occurred between 10 AM and midnight, over the course of the month-long periods. No data were collected overnight. Training of assistants consisted of individualized and group tutorials in the ED emphasizing appropriate patient interaction, proficiency training in reading patient charts, and ED flow (involving triage, medication distribution, and timing of procedures). Patients were selected without discrimination for age, sex, ethnicity, chief complaint, or pain score. Communication with nonYEnglish-speaking patients occurred via telephone translation services. Patients were physically followed up by research assistants in real time through the ED, from triage until discharge. Data

were collected either by direct observation or from the patients chart during the course of the ED stay. Certain variables were abstracted from the chart because they were objective, and it was felt that interrupting the physician workflow to inquire about these items might influence their practice (Hawthorne effect). Variables collected by direct observation include demographic information, painful procedures undertaken (including intravenous line placement and phlebotomy), use of preprocedural or periprocedural analgesia, and patient and/or parent satisfaction. Variables collected prospectively from the patients chart include chief complaint, nursing-recorded pain scores at triage and discharge, pain medications prescribed, time from triage until receipt of pain medication, and documented reassessment of pain by physicians and nurses. Pain scores were obtained using self-report scales (Faces Pain ScaleYRevised and numeric and visual analog scales) and observational scales (FLACC [Faces, Legs, Activity, Cry, and Consolability] scale); all were converted to a 0- to 10-point numeric pain rating. Satisfaction scores at discharge were collected

FIGURE 2. Bellevue ED pain posters. * 2012 Lippincott Williams & Wilkins www.pec-online.com

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TABLE 1. Demographics of Preintervention (July 2008) and Postintervention (July 2009) Data Sets Preintervention Postintervention Patients enrolled Mean triage pain (1Y10) Female sex Mean age (range), y No. patients aged G4 y No. patients aged 4Y8 y No. patients aged 98 y Type of pain, by system Headache/earache/throat pain Musculoskeletal Gastrointestinal Gynecologic/genitourinary Skin: rash/burns Skin: bruises/lacerations Respiratory Cardiovascular 102 5.3 58% 15.5 (0.17Y25) 11 11 80 23% 21% 16% 12% 11% 10% 5% 2% 109 5.6 54% 16.9 (0.58Y24) 7 13 93 27% 21% 14% 8% 11% 10% 5% 4%

language brochures, handouts upon admission, and the creation of posters informing patients of their right to proper pain management (Fig. 2).

Statistical Analysis
Data were analyzed using independent-samples t test for continuous variables and W2 Fisher exact test for proportions. We calculated a sample size of 100 per group to allow for 80% power to detect a 20% difference (chosen as a clinically meaningful difference) between rates of analgesic administration to patients in pain before and after the intervention. Data were analyzed using SPSS software version 15 (SPSS Inc, an IBM Company, Chicago, Ill).

RESULTS
The patient populations enrolled in each phase of the study were similar with respect to sex, age, and pain score at triage (Table 1). A comparison of the primary and secondary outcomes between the 2 collection periods is shown in Table 2. The percentage of patients with a pain score of at least 4/10 who received any analgesic in the ED increased from 34% before intervention to 50% after intervention, an absolute increase of 16% (95% confidence interval [CI], 1%Y30%). The median time to medication administration decreased from 97 minutes to 57 minutes, an absolute decrease of 40 minutes (95% CI, j84 minutes to 4 minutes). The percentage of patients receiving analgesics before or during painful procedures increased from 10% to 62%, an absolute increase of 52% (95% CI, 12%Y74%). Reassessment of pain by physicians increased from 6% to 76%, an absolute increase of 70% (95% CI, 59%Y78%), whereas reassessment by nurses increased from 75% to 82%, an absolute increase of 7% (95% CI, j4% to 18%). Those reporting a decrease in pain score from the time of triage until the time of discharge decreased from 46% to 40%, an absolute decrease of 6% (95% CI, j9% to 2%). Patient satisfaction increased from 3.48 to 3.54, an absolute increase of 0.06 (95% CI, j0.13 to 0.25)

using a 4-point Likert scale, with 1 representing very unsatisfied and 4 representing very satisfied. Institutional review board approval was granted before initiation of the study.

Outcomes
The primary outcome of interest in this study was the treatment of patients in moderate or severe pain (a pain score of a least 4/10 as determined by the triage nurse) with any analgesic. Secondary outcomes included the timeliness of analgesic administration (the time from triage until receipt of medication), whether those undergoing painful procedures received topical anesthetics (lidocaine and/or prilocaine cream or spray) beforehand, whether those presenting with moderate or severe pain score experienced a significant reduction in pain (considered to be a difference of 2/10 from triage to discharge), documented reassessment of pain, and patient satisfaction.

DISCUSSION
To the best of our knowledge, this study is the first to evaluate the impact of a multidisciplinary intervention to improve pain management in the pediatric emergency medicine setting. Our data show the intervention resulted in improved rates of analgesic administration to those in pain, as well as improved

Intervention
After the initial data collection, a multidisciplinary committee was formed, composed of faculty and senior house staff from the departments of pediatrics, emergency medicine, and anesthesiology, as well as nursing leadership and leadership from the child life service. The committee reviewed preintervention data and developed a pain policy, structured around areas of poor performance, changes we thought were feasible to make, and existing guidelines for care standards that were not being met. Guidelines used in the development of the program include recommendations from the American Academy of Pediatrics,21 as well as the Boston Medical Center Pediatric Procedural Pain Management Guide.25 The policy is attached in full as a supplement (Supplementary Digital Content 1, http://links.lww.com/PEC/A9). It focuses on assessment using proper pain scales, pain being recorded as the fifth vital sign, treatment with both pharmacologic and nonpharmacologic methods with active involvement of child life, a triage-based pathway for patients in moderate or severe pain to receive analgesics immediately, the use of topical anesthetics or oral sucrose for painful procedures, pain reassessment, and discharge pain action plans. The policy was then disseminated to house staff and nursing via education programs and to patients and parents via the distribution of plain

TABLE 2. Comparison of Primary and Secondary Outcomes in Preintervention and Postintervention Periods Pre Post Difference (95% CI)

Received any analgesic 34 50 16 (1Y30)* in the ED, % Median time to 97 min 57 min j40 (j84 to 4) analgesia, min Preprocedural analgesia, % 10 62 52 (12Y74)* Pain reassessed by MD, % 6 76 70 (59Y78)* Pain reassessed by RN, % 75 82 7 (j4 to 18) Decreased pain score at 46 40 j6 (j9 to 2) d/c, % Mean satisfaction (1Y4) 3.48 3.54 0.06 (j0.13 to 0.25)
*Statistically significant. Pre indicates preintervention; Post, postintervention; d/c, discharge; RN, registered nurse; MD, physician.

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timeliness of a analgesic administration, improved rates of pain reassessment, and an increased use of preprocedural and periprocedural analgesia. There was not, however, an improvement in the percentage of patients experiencing a significant decrease in pain score before discharge. This may have resulted from better use of observational pain scales, or the slight increase in the percentage of patients presenting with headaches, earaches, or throat pain in the postintervention collection, which are notoriously difficult to treat. In addition, although there was no improvement in patient satisfaction scores, this outcome was already quite high in the preintervention phase. Previous studies have shown patients often report high satisfaction levels despite inadequate treatment.26 In developing this program, 2 elements were considered essential. Baseline data were obtained not only before the implementation but also before the development of the intervention. This allowed the intervention to be targeted to departmentspecific deficiencies, as well as the ability to cite quantitative data during training programs to motivate change. Second, a multidisciplinary approach was undertaken. Committee meetings included not only physicians but also members of the departments of nursing and child life, and such meetings helped to generate enthusiasm for improving pain management among multiple disciplines. Areas for improvement identified during baseline data collection included treating pain at triage, treatment of procedural pain, and pain assessment and reassessment. A triage-based clinical pathway for analgesic administration was implemented, which allowed nurses to alert physicians immediately of patients requiring pain medication and to up-triage those in severe pain. To better treat pain experienced during procedures, we increased the availability of topical analgesics and sucrose, which have been shown in multiple studies to reduce procedural pain in children27,28 and infants.29 Our state does not allow standing medication orders; therefore, nurses were encouraged to immediately alert physicians of patients with pain greater than 4/10 to promptly administer oral or intravenous analgesia, or patients who would be receiving phlebotomy or intravenous line placement to administer topical analgesia. To address assessment, appropriate pain scales were made more readily available, especially observational scales, which have been shown to properly evaluate pain in the youngest patients in the pediatric ED in prior studies.30Y32 An area for pain documentation was added to the patient chart, and the measurement of pain as the fifth vital sign was emphasized in training programs. Finally, patients were encouraged to advocate for their own pain management through dissemination of handouts and posters, written in plain terminology and multiple languages. Limitations of this study include its small sample size, the small proportion of younger children represented in the sample, and the use of convenience sampling. Although we estimated a sample size of 100 in each group would allow for detection of a statistically significant difference in our primary outcome, after conducting data analysis, we realized our sample should have been larger to evaluate this program. The generalizability of our study to other EDs may be limited by its small enrollment of younger children. Older children were overrepresented in the convenience sample enrolled, which precluded age-specific subanalyses. Other limitations include a potential Hawthorne effect among treating physicians, which was minimized by limiting contact of data collectors with care providers. Any Hawthorne effect would have occurred in both the preintervention and postintervention phases and therefore likely affected both groups equally. Finally, July data collection led to a portion of treating providers consisting of new interns. Part of the training
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program was repeated for incoming house staff; however, the inability to fully readminister the intervention before data collection may have diluted the effect of the policy. Although this study showed our program effectively improved several areas of pain management, further studies are needed to establish which interventions were most valuable in changing practice. Other institutions may wish to evaluate a single targeted intervention, using the tiered approach adopted in this study (implementation of a policy, education of providers, and dissemination), as a more effective method of implementing change. Enrollment of more patients in the younger age group, and/or a study design stratifying patients by age and pain scores, would allow for proper analysis of the effectiveness of our intervention among young children. Finally, assessment of continued interventions beyond the 6-month period that was observed in this study is needed to evaluate the long-term effects of such a program.

CONCLUSIONS
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.
ACKNOWLEDGMENTS The authors thank Dr Benard Dreyer and all the members of the Bellevue Pain Reduction Committee for their dedication to improving pain management. They also thank Dr Knox Todd for his contributions in reviewing the manuscript. REFERENCES
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