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Structures of paediatric pain management: a PERUKI service evaluation study
Sheena Durnin1,2,3, Michael J Barrett4,5, Mark D Lyttle6,7
1Paediatric Emergency Medicine, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
Insights
Childhood pain management in emergency departments shows significant variation in assessment and treatment. Improving structures and implementing consistent practices are crucial for better pediatric pain outcomes.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Quality Improvement
- Pain Management
Background:
- Pain is prevalent in pediatric emergency department (ED) visits but often under-recognized and undertreated.
- National audits reveal persistent suboptimal outcomes in pediatric pain management.
- The Donabedian framework highlights the need to evaluate care quality through structures, processes, and outcomes.
Purpose of the Study:
- To benchmark variations in the assessment and management of childhood pain across healthcare networks.
- To explore network-level structures supporting analgesic practices in pediatric EDs.
- To identify interventions for improving adherence to national pain management standards.
Main Methods:
- An online survey was distributed to 40 pediatric EDs between December 2016 and January 2017.
- The survey assessed health system structures including pain assessment tools, protocols, training, guidelines, and analgesic availability.
- Data on structures, processes, and outcomes were analyzed to identify potential interventions.
Main Results:
- 95% of sites responded, representing a significant portion of the annual pediatric ED census.
- Availability of key analgesics like topical wound anesthesia (76%) and oral diclofenac sodium (58%) varied.
- Mandatory pain assessment was common (89%), but policies on assessment frequency (47%) and alignment with national guidance (55%) were inconsistent. Staff training (37%) and mandatory competencies (61%) were lacking.
Conclusions:
- Substantial variations in pain assessment and management structures exist across pediatric EDs, despite national guidelines.
- Lack of uniformity in structures is a likely cause of persistent suboptimal pediatric pain management.
- A comprehensive, person-centered approach utilizing effective interventions is needed to improve pediatric pain outcomes.
Background:
Pain is very common in childhood emergency department (ED) attendances, but is under-recognised and undertreated. Sequential national paediatric analgesia audits demonstrate suboptimal outcomes in several domains. The Donabedian framework examines the structures, processes and outcomes to evaluate quality of care. To date there has been no network-level exploration of structures supporting analgesic practices or attempts to address failure to attain national standards.
Objective:
To benchmark current variation in assessment and management of childhood pain at network level.
Methods:
Online survey distributed between December 2016 and January 2017 exploring health system structures including pain score tools, pain assessment/protocols, training, practice guidelines and analgesic agent usage. We explored structures, processes and outcomes to identify interventions, and their potential effectiveness and feasibility.
Results:
In total 95% (38/40 sites) responded, including 25 tertiary (66%) and 13 secondary hospitals (34%), with a total annual paediatric ED census of 1 225 000 (range 11 500-65 000). Availability of analgesics varied included topical wound anaesthesia in 29/38 sites (76%), oral diclofenac sodium in 22/38 sites (58%) and tramadol in 16/38 sites (42%). Pain assessment was mandatory in initial assessment in 34/38 sites (89%), and 18/38 sites had a policy on frequency of pain assessment (47%). Local guidance aligned with national guidance in 21/38 sites (55%). There was no staff training at induction/orientation in 14/38 sites (37%) and no mandatory competencies in pain management in 23/38 sites (61%). Play specialist services were available in 21/38 sites (55%).
Conclusion:
Despite national guidance and recommendations from multiple audits, there are substantial variations in structures relating to pain assessment and management across sites. The lack of uniformity is a likely root cause for the persistent suboptimal practices identified by serial national audits. A whole system and person-centred approach to improving pain outcomes by utilising effective interventions seeks to improve paediatric pain outcomes.
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