Original ContributionComprehensive pain management protocol reduces children's memory of pain at discharge from the pediatric ED☆
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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2021, HeliyonCitation Excerpt :Thus, EDs with higher recidivism rates may be at risk for scoring poorly on key pain control and patient satisfaction metrics based on census characteristics that are, clearly, outside the sphere of physician influence. Investigators previously have evaluated the assessment and treatment of pain in the ED from a variety of perspectives 1, 5, 6, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56 Several have evaluated serial assessments of pain and noted a frequent lack of improvement and/or satisfaction despite treatment [11, 12, 13] Todd et al. conducted a telephone survey of 500 adult patients with either chronic or recurrent pain who reported an ED visit within the past two years [11]. Less than half the patients in both groups reported following treatment that they felt “complete” or “a great deal” of pain relief.
Implementation of paediatric pain care-bundle across South-West England clinical network of Emergency Departments and Minor Injury Units: A before and after study
2019, International Emergency NursingCitation Excerpt :The UK National Service Framework (2004) highlighted the right of a child to expect appropriate assessment and management of pain [2]. Yet several papers highlight continuing practice deficiencies in emergency departments [3–5]. Barriers to the effective management of pain in children include misconceptions regarding the ability of children to perceive pain [6], a lack of understanding as to how to assess pain across different age groups [7], a fear of over-dosage of analgesia [7], and a concern that analgesia may mask symptoms [8,9].
Safety and effectiveness of intranasal midazolam and fentanyl used in combination in the pediatric emergency department
2019, American Journal of Emergency MedicineCitation Excerpt :Similarly, several studies have shown intranasal fentanyl (INF) to be safe and effective for managing acute pain in the pediatric emergency department, especially with regard to orthopedic injuries [13-16]. In April of 2009, intranasal medications were introduced in our Pediatric Emergency Department (PED) as part of the Comfort Zone initiative, aimed at recognizing and reducing pain and anxiety in children [17]. Since that time, it has become common practice to utilize INM and INF in combination for minor procedures, such as laceration repair, in the PED.
Thoracostomy Tube Removal: Implementation of a Multidisciplinary Procedural Pain Management Guideline
2017, Journal of Pediatric Health CareCitation Excerpt :Multiple studies have observed thoracostomy removal pain in adults (e.g., Akrofi et al., 2005; Bruce, Howard, & Franck, 2006); however, few studies have focused on pediatric thoracostomy tube removal pain (Puntillo & Ley, 2004; Rosen et al., 2000). Although evidence exists for the efficacy of pediatric pain management (Cregin et al., 2008; Crocker, Higgenbotham, King, Taylor & Milling, 2011), translation of this knowledge for treatment of procedural pain into clinical practice remains a challenge (Buscemi, Van Dermeer, & Curtis, 2008; Ortiz, Lopez-Zarco, & Arreola-Bautista, 2012; Petovello, 2012). Optimizing procedural pain relief during initial congenital heart surgeries may help reduce pain with future procedures, because acute pain can lead to stimulation of the stress response and result in changes to major organ systems (Taddio & Katz, 1997; Simone & Scorce, 2012; Weisman, Bernstein, & Schechter, 1998).
Do abused young children feel less pain?
2017, Child Abuse and NeglectCitation Excerpt :Improving the management of acute pain in these children could reduce the long-term consequences of inadequately treated pain, according to the phenomenon of memory of pain and chronicity of pain. Indeed, inadequately treated pain increases the pain experienced during subsequent episodes as well as a fear of care, or a phobia, a loss of confidence in adults, and behavioral and anxiety disorders (Anand, Grunau, & Oberlander, 1997; Taddio, Katz, Ilersich, & Koren, 1997; Zonneveld, McGrath, Reid, & Sorbi, 1997; Crocker, Higginbotham, King, Taylor, & Milling, 2012; Grunau, 2013; Von Baeyer, Marche, Rocha, & Salmon, 2004). The authors have indicated they have no potential conflicts of interest to disclose.
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This study was partially funded by a grant from the Dell Children's Foundation.