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Prescription of analgesia in emergency medicine (POEM) secondary analysis: an observational multicentre comparison of pain relief provided to adults and children with an isolated limb fracture and/or dislocation
  1. Sarah Wilson1,
  2. Jane Quinlan2,
  3. Sally Beer3,
  4. Melanie Darwent3,
  5. Jack R. Dainty4,
  6. James Robert Sheehan5,
  7. Liza Keating6
  1. 1 Emergency Department, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
  2. 2 Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, Oxfordshire, UK
  3. 3 Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
  4. 4 Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
  5. 5 Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
  6. 6 Intensive Care Unit, Royal Berkshire NHS Foundation Trust, Reading, UK
  1. Correspondence to Dr Sarah Wilson, Emergency Department, Wexham Park Hospital, Slough SL2 4HL, UK; sarah.wilson2{at}


Background Acute pain is a common reason for emergency department (ED) attendance. Royal College of Emergency Medicine (RCEM) pain management audits have shown national variation and room for improvement. Previous evidence suggests that children receive less satisfactory pain management than adults.

Methods Prescription of analgesia in emergency medicine is a cross-sectional observational study of consecutive patients presenting to 12 National Health Service EDs with an isolated long bone fracture and/or dislocation, and was carried out between 2015 and 2017. Using the recommendations in the RCEM Best Practice Guidelines, pain management in ED was assessed for differences of age (adults vs children) and hospital type (children’s vs all patients).

Results From the total 8346 patients, 38% were children (median age 8 years). There was better adherence to the RCEM guidance for children than adults (24% (766/3196) vs 11% (579/5123)) for the combined outcome of timely assessment, pain score and appropriate analgesia. In addition, children were significantly more likely than adults to receive analgesia appropriate to the pain score (of those with a recorded pain score 67% (1168/1744) vs 52% (1238/2361)). Children’s hospitals performed much better across all reported outcomes compared with general hospitals.

Conclusions In contrast to previous studies, children with a limb fracture/dislocation are more likely than adults to have a pain score documented and to receive appropriate analgesia. Unexpectedly, children’s EDs performed better than general EDs in relation to timely and appropriate analgesia but the reasons for this are not apparent from the present study.

  • pain management
  • analgesia/pain control
  • emergency department
  • musculo-skeletal
  • fractures and dislocations
  • paediatrics
  • paediatric injury

Data availability statement

Data are available on reasonable request. After publication of the planned primary and secondary analyses, the trial data can be shared on reasonable request to the corresponding author.

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Data availability statement

Data are available on reasonable request. After publication of the planned primary and secondary analyses, the trial data can be shared on reasonable request to the corresponding author.

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  • Handling editor Jo Daniels

  • Twitter @sarah_EMdoc, @RN_salbee, @jrsheehan24

  • Collaborators Stuart Hartshorn, Katy Pettit, Karen Faulkner and Anna Smith (Birmingham Children’s Hospital, Birmingham’s Women’s and Children’s NHS Foundation Trust); Rachel Wharton, Sarah Moreton, Denise Maitland and Stephanie Jones (Dorset County Hospital NHS Foundation Trust); Alison Walker and Rachel Worton (Harrogate and District NHS Foundation Trust); Peter Thomas, Antoanela Colda, Charlotte White and Gill Ritchie (Milton Keynes University Hospital NHS Foundation Trust); Melanie Darwent, Sally Beer, Alexis Espinosa, Dominique Georgiou, Louise Findlay, Holly Coles, Jose Martinez, Alex Novak, Amanda Budden, Soubera Rymell, Peter Chater-Lea, Sandy Farrow, Hannah Ward and Neil Dawson (Oxford University Hospitals NHS Foundation Trust–John Radcliffe Hospital and Horton General Hospital); James Sheehan, Liza Keating, Sarah Kempster, Katie Keating-Fedders, Will Orchard, Christina Ambrose, Carys Jones, Justine Loh, Nicola Jacques, Gemma Grimwood, Nyla Haque, Charlotte Philips, Victoria Murray, Carl Evans, Rachel Brooke, Lucie Tesarova and Claire Burnett (Royal Berkshire Hospital NHS Foundation Trust); Alasdair Gray, Mia Paderanga, Adam Lloyd, Kate Easterford, Emma Ward and Rachel O’Brien (Royal Infirmary of Edinburgh); Stuart Gormley, Nick Weatherhill and Shammi Ramlakha (Sheffield Children’s NHS Foundation Trust); Anthony Kehoe, Jason Smith, Rosalyn Squire and Alison Jeffery (University Hospitals Plymouth NHS Trust); Sarah Wilson, Louise Chandler, Joana Da Rocha, Saheli Das, Louise Foster, Gail Warren, Thanuja Weerasinghe, Clare Gargini and Maria Cruz (Wexham Park Hospital, Frimley Health NHS Foundation Trust).

  • Contributors LK and JQ conceived the survey. JRS was the chief investigator. LK, JQ, MD, SW and PT were coinvestigators on the protocol. Martyn Ezra drew up the initial statistical strategy and JD performed the statistical analysis. SB contributed to the entirety of the project together with the other investigators. SW wrote the first draft of the manuscript; all authors revised this draft. All authors read and approved the final version.

  • Funding Initial funding was received from an RCEM research grant and the study was subsequently adopted onto the NIHR portfolio.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the RCEM or the NIHR.

  • Competing interests JD reports personal fees from Royal Berkshire Hospital during this analysis of the study and personal fees from Reading University during the conduct of the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.