C Hawkes, G Kelleher, J Hourihane Cork University Hospital, Wilton, Cork
Abstract Timely management of pain in paediatric patients in the Emergency Department (ED) is a well-accepted performance indicator. We describe an audit of the provision of analgesia for children in an Irish ED and the introduction of a nurse-initiated analgesia protocol in an effort to improve performance. 95 children aged 1-16 presenting consecutively to the ED were included and time from triage to analgesia, and the rate of analgesia provision, were recorded. The results were circulated and a nurse initiated analgesia protocol was introduced. An audit including 145 patients followed this. 55.6% of patients with major fractures received analgesia after a median time of 54 minutes, which improved to 61.1% (p=0.735) after 7 minutes (p=0.004). Pain score documentation was very poor throughout, improving only slightly from 0% to 19.3%. No child had a documented pain score, which slightly improved to 19.3%. We recommend other Irish EDs to audit their provision of analgesia for children.
IntroductionTimely management of pain in paediatric patients in the Emergency Department (ED) is a well-accepted performance indicator1,2. Children have been shown to be less likely than adults to receive analgesia3-5 in the ED setting, particularly opioids6,7. While this has been well documented in other countries, and has been used to compare performance across EDs, little is known of the success of Irish EDs in providing prompt analgesia for their paediatric patients.
The aim of this study is to describe the provision of analgesia for paediatric patients in a large Irish ED, and to analyse and modify the protocol in this hospital with a view to improving the quality of care provided for children. The study was conducted in the ED of Cork University Hospital (CUH), a third level trauma centre that serves both adults and children. 50,000 patients attend the CUH ED each year, 10,000 of whom are children. This ED does have a separate children’s waiting area, but paediatric nurses are not specifically assigned to this area.
MethodsThis study consisted of an audit to assess the provision of analgesia for paediatric patients, interventions to improve this, and a repeat study to assess the effect of the interventions. The ED protocol for the provision of analgesia for children in CUH was the recommended protocol by the British Association for Emergency Medicine (BAEM)8, which involved the recording of a self-reported pain score and the administration of appropriate analgesia guided by this score. This hospital protocol did not, however, specify who should document the pain score.
Pre-interventional AuditUsing the CUH Patient Information Management System (PIMS), the first 95 patients aged 1-16 presenting to the ED prior to a designated time were identified and included in this retrospective audit. Excluded were patients presenting via ambulance and children with infectious respiratory diagnoses. Infectious respiratory diagnoses were excluded as they are usually not painful and, due to seasonal variation, inclusion may have introduced an obvious discrepancy between patient groups. Patient medical notes were the source of information used for this audit. Patient age, sex, pain score and discharge diagnosis were recorded, as was the time from triage to the prescription of analgesia. Details on non-pharmacological pain control such as splinting and distraction were not collected although their importance is acknowledged9. The adequacy of the medication used was also not recorded as this would have required repeat pain score measurement, which was not performed in any patient in this department.
The target of an emergency department regarding analgesia is to correctly identify children in pain, and to provide effective analgesia promptly when required. Almost all patients with a major fracture (long bone, clavicle or rib) are in pain and should receive analgesia. The percentage of these patients receiving analgesia in the ED was thus used as an indicator of the adequate identification of children in pain. The time from triage to analgesia was used as an indicator of the efficiency of the provision of analgesia. All patients receiving analgesia in the ED, regardless of diagnosis, were also included in the indicator of efficiency.
InterventionsDiscussion with the staff nurses and physicians identified difficulties with the initial protocol. Discontent with the pain scoring system in the protocol, as well as confusion regarding each staff member’s specific role in the implementation of the protocol, were noted.
The Alder Hey Triage Pain Score (AHTPS) (Table 1)10 was introduced to replace the Wong Baker Faces Pain Score (WBFPS)11, which had been central to the previous protocol. Unlike the WBFPS, the AHTPS has been validated for use in the triage of children aged 0-16 in the ED. The AHPTS also has the advantage of being an observational pain scoring system, and is thus easier to perform in the ED setting. Posters outlining the AHTPS were placed in triage, and in the paediatric waiting area.
Each staff member’s role in the protocol was also definitively outlined. The triage nurse assumed responsibility for recording the pain score of every paediatric patient. It was then the role of the nurse monitoring the paediatric waiting area to ensure that the child was provided with analgesia reflecting this pain score in accordance with the protocol. Such paediatric analgesia protocols, initiated by the nurse in the triage area, reduce the time taken for analgesia to be provided and increase the overall provision of analgesia12-14. In countries where nurse prescribing of simple analgesic medications is not practiced, as in Ireland, this is a practical and accessable alternative.
Results of the initial audit, as well as an outline of the protocol were provided in printed format to all nurses and physicians working in the ED. ED consultants also informed nurses and physicians of the changes during teaching sessions. Nurses were provided with laminated pocket cards outlining the AHTPS and the analgesic protocol in order to facilitate compliance. A poster was placed in the paediatric waiting area advising parents to inform a nurse if their child was experiencing pain.
These interventions were presented at the ED quality improvement team meetings and the operation policy group meetings, and were subsequently approved.
Post-interventional AuditA second audit was performed after the interventions using the same methodology as the pre-interventional audit involving 145 patients. A larger number of patients were included in the postinterventional audit than in the pre-interventional audit in order to have similar numbers of patients with major fractures in both groups.
Statistical AnalysisData from both audits were compiled using Statistical Package for the Social Sciences (SPSS). The percentage of people with major fractures receiving analgesia was compared between the baseline pre-interventional audit and the post-interventional audit. Median time from triage to analgesia was also compared between the groups and statistical significance between the medians in both independent groups determined using the Mann-Whitney U test.
Results240 patients in total were involved in this study. There were 95 patients in the pre-interventional group, and 145 in the postinterventional group. Characteristics of the pre-interventional and post-interventional groups are shown in Table 2. While slight differences are noticed between the ages and diagnostic categories in each group, this is not considered to impact on subsequent analysis.
* Miscellaneous: epistaxis, foreign body ingestion, rash, urinary tract infection, limp,febrile convulsion, cellulitis, migraine, conjunctivitis, infecious mononucleosis, paronychia, muscular chest pain.
Results are shown on Table 3 and Fig 1. Of note, the absent documentation of the pain score in all patients in the preinterventional group highlights the poor compliance with the previous protocol, which was centred around the recording of a pain score prior to deciding upon the analgesic medication of choice. Following introduction of the AHTPS (Table 1), 19.3% (n=28) of patients in the post-interventional group had a documented pain score and these are the only patients in whom the protocol could have been followed. Of those patients, in whom pain score was recorded, 53.6% (n=15) received analgesia after a median time of 14 minutes (interquartile range 5 - 45 minutes). 4 of those patients were in the major fractures group.
Analgesia was documented as given prior to attending the ED in 0% of the pre-interventional group and 13.1% of the postinterventional group. These patients were excluded in calculating the percentages of patients with major fractures receiving analgesia. 55.6% of patients with major fracture in the preinterventional group received analgesia, which improved minimally to 61.1% in the post-interventional group, but this was not statistically significant (p=0.735).
* Patients receiving pre-hospital analgesia were excluded from this total and percentage
The median time from triage to analgesia in patients with major fractures improved from 54 to 7 minutes following interventions, and this was statistically significant (p=0.004). There was no statistically significant difference in the median time from triage to analgesia in patients with all other discharge diagnoses (p=0.794).
DiscussionIn a busy Irish ED, efficient analgesia delivery can be difficult to achieve. However, the prompt provision of analgesia is even more important in a busier ED, where waiting times may be longer. Analgesia delivery should have a high priority in this setting.
The results of this pre-interventional audit are consistent with findings in other countries. For example, in the UK in 2004 only 53% of children with moderate or severe pain after a fractured wrist or elbow received analgesia within 1 hour of arrival in the ED, and only 10% had pain scores recorded15. Despite the existence of a protocol in this hospital, pain scores were not being recorded, and analgesia administration was sub-optimal. This problem was due to confusion regarding the role of each staff member in the protocol, as well as difficulties with a self-reported pain scoring system in the acute setting.
Although pain score was not documented in the initial audit, 55.6% of patients with a major fracture did receive analgesia. Obvious deformity and obvious pain will, and should, prompt analgesia in the absence of a protocol, and it is likely that this was the case in these patients. It is possible that, when faced with a child with an obvious deformity, staff members deviated from the protocol, in that they assumed that the child would have a high pain score and proceeded with analgesia administration.
The assessment of pain should be performed initially in every patient in order to alert staff of the possible requirement of analgesia, and it should also be reassessed later in the child who had not been experiencing pain as the situation may change. Also, pain score should be recorded once more following the delivery of analgesia as it is the best method of assessing whether or not adequate analgesia has been provided. It could be argued that the presence of an obvious deformity at initial presentation could obviate the need for a formal pain score and automatically classify the child in the “high” pain group, but no pain scoring system currently takes this into account.
Following interventions, which increased awareness of the problem, clearly defined the role of each staff member in the nurse-initiated protocol and promoted the use of an observational pain score, a significant improvement in the time from triage to analgesia was noted in patients with major fractures. A change in the median time to analgesia from 54 to 7 minutes (p=0.004) brought the department to an acceptable standard in dealing with patients with major fractures.
Patients with painful conditions, other than major fractures, did not experience such a marked improvement in the time from triage to analgesia. This group had been receiving analgesia promptly prior to the interventions, and this may reflect the very painful conditions included in this group such as burns, dislocations and lacerations. Prompt delivery of analgesia to the children in obvious distress, while failure to provide analgesia for those perceived to be in less pain, may have caused the time from triage to analgesia in this group to be in the desirable range, while the provision of analgesia may have still been inadequate. Failed documentation of pain score in the department made it impossible to study this further.
The most disappointing results of this audit are that, following interventions, 38.9% of patients with major fractures were still treated without the provision of analgesia in the department, a lack of significant improvement on the 43.4% beforehand. The protocol could only have been followed in a maximum of 19.3% of patients in whom a pain score was recorded in the postinterventional audit. Pain score documentation alone has been shown to improve the provision of analgesia16 and should not be ignored. Promotional pocket cards, posters and consultant delivered information at educational meetings were insufficient to receive a satisfactory compliance rate with the protocol.
This audit has shown that the provision of analgesia for paediatric patients in one Irish hospital, which had not previously audited its performance, was sub-optimal. All Irish EDs are urged to audit their own practice and make alterations to their protocols, if required. While nurse initiated analgesia protocols have been shown to be effective, their implementation will need to be monitored in order for compliance to be assured.
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