The way you manage pain in kids may need revamping |…

The way you manage pain in kids may need revamping

Is pain managed well in your ED? Unfortunately, the answer to that question might depend on the age of your patient.

"In general, vulnerable populations such as children and elderly receive poor pain management by nurses and physicians," says Sylvie LeMay, RN, PhD, a researcher at the University of Montreal in Canada. "Both groups have similarities. They rely on health professionals to evaluate and manage their pain, they require an appropriate scale to measure their pain, and they do not express their pain in a direct manner — more as a change in behavior."

To assess how well ED nurses managed pediatric pain at University of Montreal's ED, LeMay performed a retrospective chart review of 150 children who presented with a painful diagnosis, including acute abdomen, burn, fracture, sprain, and deep laceration. Only 59% (89) had their pain evaluated, and of this group, only 3% (3) had a pain score documented. Only 36% were given an analgesic before a painful procedure.

Next, the researchers evaluated ED nurses' knowledge of pain management. They identified four misconceptions:

— Children exaggerate their pain.

— Administration of an opioid to a child will induce respiratory depression.

— Pain associated with a fracture is mild and should not require an opioid.

— A child can't be in pain when playing in the waiting room.

ED nurses were given three 20-minute educational "capsules" covering evaluation of pain, the physiology of pain, and pain pharmacology.

After this intervention, researchers compared the scores of the previous group with 50 nurses who cared for a total of 450 children with a painful diagnosis. Documentation of pain improved by 30%, administration of analgesics improved by 16%, and use of nonpharmacological interventions increased by 22%.¹

LeMay credits the ED's success to these three factors:

• Education targeted the areas that nurses scored poorly on.

"Education on pain management can be very broad. We focused on specific topics related to nurses' needs," says LeMay.

• She showed ED nurses their own results.

Instead of general findings from pain management studies, LeMay presented the actual retrospective chart reviews from the ED.

• The educational intervention was made convenient for nurses.

Before coming to the ED, LeMay called the assistant head nurse to ask if it was a particularly hectic day or night. If so, she would come at another time. Also, each "capsule" was repeated about 10 times over a three-week period. "So, if a nurse missed the first session, she could then attend the second or third session," she says. "Also, I did not plan my interventions during their break and lunch period. That was very much appreciated."

Reference

Le May S, Johnston CC, Choiniere M, et al. Pain management practices in a pediatric emergency room (PAMPER) study: Interventions with nurses. Ped Emerg Care 2009; 25:498-503.

ED nurses make changes for pain interventions

At Johns Hopkins Hospital Children's Center in Baltimore, "a big push right now is to improve pain control," reports Gail Schoolden, RN, MS, an ED nurse at the hospital. ED nurses now do the following interventions to manage pain:

Apply lidocaine, epinephrine, and tetracaine (LET) topical anesthetic at triage for lacerations that need to be cleaned and repaired.
Apply lidocaine topical anesthetic on abscesses prior to incision and drainage procedures. Also apply it to the site used for lumbar punctures.
Administer intranasal fentanyl for quick pain relief. "This will sometimes help us avoid starting an intravenous line. It will sometimes help with calming a patient prior to a painful procedure," says Schoolden.
Use standing orders at triage for acetaminophen and ibuprofen, to help with fever and pain. "We have fairly strict guidelines about when we can give these medications, when they are contraindicated, and a chart for dosing based on weight," says Schoolden. "The patient will have some relief of pain while waiting to be seen, or they may start to feel better when febrile while waiting to see a provider."

Jesse Pallada, RN, ED nurse at Long Island College Hospital in Brooklyn, NY, says lidocaine was previously injected around a child's laceration, but now LET gel is applied. "We apply the gel topically to the laceration, let it sit for 30-45 minutes, and then start suturing. This is much more comfortable for the patient," he says.

Whenever a child undergoes a painful procedure at Johns Hopkins, moderate sedation is considered, says Schoolden. "It increases patient comfort and decreases anxiety," she says. "Typical procedures that we would sedate for include fracture reduction, burn debridement, incision and drainage of a large abscess, repair of a large laceration in a young child, or if it is a laceration that involves the face and requires that the child be very still."

Long Island College Hospital's ED nurses recently began using moderate sedation for procedures such as closed reduction of fractures and dislocations. "It makes it easier and less terrifying for the kid, easier and faster for the treating doctor and nurse, and less stressful for the parents," says Pallada.

Sources

For more information on improving pain management of pediatric patients, contact:

Sylvie LeMay, PhD, University of Montreal, Canada. Phone: (514) 345-4931. E-mail: [email protected].
Jesse Pallada, RN, Emergency Department, Long Island College Hospital, Brooklyn, NY. E-mail: [email protected].
Gail Schoolden, RN, MS, Pediatric Emergency Department, Johns Hopkins Hospital Children's Center, Baltimore. E-mail: [email protected].