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Published on: August 1, 2019
Impact of an Offline Pain Management Protocol on Prehospital Provider Self-Efficacy: A Randomized Trial
April Jaeger1, Nanette Dudley, Maija Holsti
1From the *Spokane Emergency Physicians, Providence Sacred Heart Medical Center & Children's Hospital, Spokane, WA; †Division of Pediatric Emergency Medicine and ‡Research Enterprise, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; §EMS for Children Program, Utah Department of Health, Salt Lake City, UT; ∥San Mateo Medical Center, San Mateo, CA; ¶Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
Insights
Implementing a pediatric pain management protocol improved prehospital provider self-efficacy in pain assessment and management, especially for children. These improvements, particularly in pain assessment, were sustained at 13 months for pediatric patients.
Area of Science:
- Emergency medicine
- Pediatric care
- Healthcare quality improvement
Background:
- Prehospital pain management for children is often inadequate.
- Prehospital providers (PHPs) recognize pain treatment as important but lack data on protocol impact.
- The effect of pediatric pain management protocol (PPP) implementation on PHP self-efficacy (SE) is unknown.
Purpose of the Study:
- To assess the impact of implementing a PPP on PHP SE.
- To evaluate the role of pain management education in enhancing PHP SE.
- To determine the long-term effects of PPP and education on provider confidence.
Main Methods:
- Prospective study with 3 PHP groups: protocol only, protocol with education, protocol with education and review.
- SE assessed using a 0-100 scale for pain assessment, medication administration, dosing, and reassessment across adult, child, and toddler scenarios.
- Paired t-tests compared pre-PPP scores with 13-month post-implementation scores.
Main Results:
- Self-efficacy scores increased significantly post-protocol, particularly for pain assessment in children and toddlers.
- Composite SE scores rose immediately for all age groups and persisted at 13 months for toddlers.
- No significant differences in SE improvement were found between groups receiving protocol review alone versus those with added education.
Conclusions:
- PPP implementation led to immediate and sustained increases in PHP SE for pain management actions, especially pain assessment.
- While adult pain assessment SE declined by 13 months, pediatric SE remained elevated compared to baseline.
- Education and interim reviews did not yield significantly different SE outcomes compared to protocol introduction alone.
Background:
Pain in children is inadequately treated in the prehospital setting despite the reported recognition by prehospital providers (PHPs) of pain treatment as an important part of patient care. The impact of pediatric pain management protocol (PPP) implementation on PHP self-efficacy (SE), a measure congruent with performance, is unknown.
Objective:
The aim of this study was to evaluate the impact of PPP implementation and pain management education on PHP SE.
Methods:
This was a prospective study evaluating the change in PHP SE after a PPP was implemented. Prehospital providers were randomized to 3 groups: protocol introduction alone, protocol introduction with education, and protocol introduction with education and a 3-month interim review. Prehospital provider SE was assessed for pain management given 3 age-based scenarios. Self-efficacy was measured with a tool that uses a ranked ordinal scale ranging from "certain I cannot do it" (0) to "completely certain I can do it" (100) for 10 pain management actions: pain assessment (3), medication administration (4), dosing (1), and reassessment (2). An averaged composite score (0-100) was calculated for each of the 3 age groups (adult, child, toddler). Paired-sample t tests compared post-PPP and 13-month scores to pre-PPP scores.
Results:
Of 264 PHPs who completed initial surveys, 142 PHPs completed 13-month surveys. Ninety-three (65%) received education with protocol review, and 49 (35%) had protocol review only. Self-efficacy scores increased over the study period, most notably for pain assessment. This increase persisted at 13 months for child (6.6 [95% confidence interval {CI}, 1.4-11.8]) and toddler pain assessment (22.3 [95% CI, 16.4-28.3]). Composite SE scores increased immediately for all age groups (adult, 3.1 [95% CI, 1.3-4.9]; child, 6.1 [95% CI, 3.8-8.5]; toddler, 12.0 [95% CI, 9.5-14.5]) and persisted at 13 months for the toddler group alone (7.0 [95% CI, 4.3-9.7]). There was no difference between groups who received protocol review alone compared with those with education or education plus a 3-month interim review.
Conclusions:
After a pain management protocol was introduced, SE scores among PHPs increased immediately and remained elevated for some individual actions involved in pain management, most notably pain assessment. Prehospital provider pain assessment SE scores declined 13 months after protocol introduction for adults, but remained elevated compared with baseline for the pediatric age groups.
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