Original Contribution
Comprehensive pain management protocol reduces children's memory of pain at discharge from the pediatric ED

https://doi.org/10.1016/j.ajem.2011.05.030Get rights and content

Abstract

Background

Historically, pain has been poorly managed in the pediatric emergency department (ED) (PED), resulting in measurable psychosocial issues both acute and delayed.

Objective

The aim of the study was to measure the impact of protocolized pain management on patients with painful conditions or undergoing painful procedures in the PED.

Methods

We performed an analysis before and after the implementation of the protocol, dubbed the “Comfort Zone.” Validated, age-appropriate pain scales were performed. Validation (using Cronbach α, confirmatory factor analysis) was followed by comparison of responses between the pre- and posttests collected (χ2 and Wilcoxon rank sum tests). Pain scores were collected at triage and at discharge. At triage, patients were asked to report pain levels. At discharge, they were asked to report their current pain and recall the level of pain during their stay. At triage, parents were asked to report about their perception of the child's pain. At discharge, they were asked to report about their perception of the child's current pain and recall the level of pain during the stay and during procedures, if done.

Results

Five hundred thirty-one patients were enrolled in the preprotocol group; 47% were women with a median age of 5 years (range, 30 days-18 years). Two hundred sixty-three patients were enrolled in the protocol group; 39% were women with a median age of 6 years (range, 30 days-18 years). Patient-recalled pain scores of the ED visit in the protocol group were significantly lower than those of the preprotocol group (Wong-Baker Faces Pain Scale, 5.07-4.01; P < .001); yet parent estimates of pain did not show a significant change at any point. Patient assessment of pain at ED discharge did not show a significant change either (Wong-Baker Faces Pain Scale, 1.99-1.56; P = .09). The Faces scale is not well validated for patients younger than 4, so that group had only parental assessment of pain and, consistent with the larger data set, showed no significant pain scale reduction at any point.

Conclusion

Protocolized pain management reduces patients' memory of pain during PED visits but may not affect parental memory of perceived pain or parent- and patient-reported pain at discharge.

Introduction

There is a long history of inadequate anxiety and pain recognition and control in the pediatric emergency department (PED) [1], [2], [3], [4], [5]. This has been documented by multiple prior studies of both parent and patient perception of pain control and anxiety-alleviating measures [3], [6], [7], [8], [9], [10], [11], [12]. A rationale for this has been an unsubstantiated assumption that children perceive pain and anxiety differently or “won't remember” or a failure to recognize the child-specific signs of pain. Furthermore, research exists indicating that children can have posttraumatic stress disorder symptoms after painful and stressful procedures in the PED [13]. There now exist medication and tools to reduce pain and anxiety that do not require intravenous access or intramuscular injection. These new devices are simple to use, painless, and not threatening, and they represent a more compassionate way to treat children.

Single interventions (eg, intranasal fentanyl or versed, isolated, distraction techniques) have shown promise in helping to ameliorate the discomfort associated with these procedures [14], [15]; however, the impact of a comprehensive protocol using multiple interventions on child and parent perception of pain has not been extensively studied.

Our institution has developed a multidisciplinary, multifaceted approach to the control of the anxiety and pain associated with painful conditions and procedures in the PED. Pharmacologic interventions were used to minimize the noxious effects of procedures and painful conditions, driven by child- and parent-reported Wong-Baker Faces pain scales [16], and were begun in triage.

The goal of this investigation was as follows: our institution gauged the effect of this protocol by measuring patient and parent pain scores before and after implementation.

Section snippets

Study methods

This study was exempted from review by the Seton Institutional Review Board.

Setting was a dedicated children's hospital, Dell Children's Medical Center, Austin, TX, with an annual PED volume of 70 000 visits.

Protocolized Pain Management Intervention “Comfort Zone” protocol: The emergency department (ED) implemented a process for creating a team approach to address pain, anxiety, and discomfort associated with the treatment for pediatric patients in the emergency setting. This program crosses

Results

Five hundred thirty-one patients were enrolled in the preprotocol group (PPG); 47% were women with a median age of 5 years (range, 0-18 years). Two hundred sixty-three patients were enrolled in the protocol group (PG); 39% were women with a median age of 6 years (range, 0-18 years).

Testing of the survey itself demonstrated it to be a reliable (Cronbach α = .96, within-section Pearson correlation coefficients >0.6) measurement tool. Internal validity testing with principal component factor

Limitations

Although we have a protocol, a group of interventions that together reduce child pain, we cannot distinguish to what degree each intervention individually affected pain reduction. This would be an area for further study.

Logistically, we were only able to collect the pain scores at 2 time points, that is, triage and discharge, and this required patients and parents to recall pain levels during their stay, so the data are subject to recall bias. However, this bias would have had the same effect

Discussion

The appropriate treatment for acute painful conditions and the management of procedure-related pain in children has long been a topic of study and practice criticism [2], [3]. Prior studies have reported the failure to use analgesics at all in some cases, late administration of analgesics, improper selection of analgesic, and inadequate dosing [1], [5]. Studies have found that children are less likely than adults to receive analgesia for extremity fractures in the ED [4].

The failure to

Conclusion

We have demonstrated an effective protocol to reduce the remembered perception of pain by children undergoing painful procedures or having painful conditions in the PED.

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    This study was partially funded by a grant from the Dell Children's Foundation.

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