An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management

Evidence-Based Guidelines for Prehospital Pain Management: Recommendations

This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.

Transport of the patient with trauma: a narrative review

Trauma and injury place a significant burden on healthcare systems. In most high-income countries, well-developed acute pre-hospital and trauma care systems have been established. In Europe, mobile physician-staffed medical teams are available for the most severely injured patients and apply a wide variety of lifesaving interventions at the same time as ensuring patient comfort. In trauma systems providing pre-hospital care, medical interventions are performed earlier in the patient journey and do not affect time to definite care. The mode of transport from the accident scene depends on the organisation of the healthcare system and the level of hospital care to which the patient is transported. This varies from 'scoop and run' to a basic community care setting, to advanced helicopter emergency medical service transport to a level 4 trauma centre. Secondary transport of trauma patients to a higher level of care should be avoided and may lead to a delay in definitive care. Critically injured patients must be accompanied by at least two healthcare professionals, one of whom must be skilled in cardiopulmonary resuscitation and advanced airway management techniques. Ideally, the standard of care provided during transport, including the level of monitoring, should mirror hospital care. Pre-hospital care focuses on the critical care patient, but the majority of injured patients need only close observation and pain management during transport. Providing comfort and preventing additional injury is the responsibility of the whole transport team.

An EXploration of the facilitators and barriers to paramedics' assessment and treatment of pain in PAediatric patients following Trauma (EX-PAT)

Background:

Pain is a common symptom among patients presenting to ambulance services and is often associated with traumatic injury. Assessment and management of pain in children in the pre-hospital setting is suboptimal. This study aimed to understand the facilitators and barriers experienced by paramedics in their assessment and management of pain in children who have sustained traumatic injuries.

Methods:

Face-to-face, audio-recorded semi-structured interviews using a piloted topic guide were conducted with paramedics employed by South Central Ambulance Service NHS Foundation Trust. Interviews were professionally transcribed, coded manually and analysed using thematic analysis.

Results:

Eleven interviews were conducted; three themes related to assessment and three related to management were identified. Previous positive experiences of utilising pain scoring tools were identified as a facilitator to pain assessment, whereas a lack of confidence in using pain scoring tools was a barrier. Patients’ understanding of and compliance with the tools were both a facilitator and a barrier to assessment. Facilitators to management included personal sub-themes of colleagues/others, exposure, being a parent, technology, severity of the injury and subjective pain scoring. Organisational facilitators included medicines, routes, and alternative methods. Situational facilitators included patient-specific solutions and parents. Five personal barriers to management included medicines, skill, consequences to self or patient, negative interactions, and limited exposure. Three organisational barriers included medicines and routes, equipment issues and choices, and training and culture. Within the theme of situation, two sub-themes emerged: patient-specific issues and environment-specific issues. Novel facilitators to emerge were those of alternative methods and being a parent.

Conclusion:

A multitude of factors incorporating situational, organisational, and personal all combine to determine how paramedics treat paediatric trauma patients. A multi-stakeholder approach to providing clearer assessment tools, improved education, equipment, and pharmacy options may improve assessment and management compliance for the benefit of the patient.

Emergency care providers' perspectives of acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa: A qualitative study

INTRODUCTION

A growing body of evidence suggests that pain knowledge and management are poor, perhaps more so in the prehospital setting. The daily challenges that emergency care providers face in dealing with prehospital pain remain unclear. This study aimed to gain a deeper understanding of acute prehospital pain assessment and management in the Western Cape, South Africa.

METHODS

A series of focus group discussions, using a constructivist paradigm and qualitative content analysis were conducted.

RESULTS

The key themes emerging from six focus groups (total 25 emergency care providers) related to the difficulties of assessing pain in this setting, factors affecting clinical reasoning in this (hostile) setting, the realities of prehospital pain care for non-advanced life support practitioners, along with emergency departments' lack of understanding and appreciation of the prehospital environment, and participants' suggestions to improve pain practice.

CONCLUSION

Several barriers and enablers, some novel, to pain assessment and management in the South African prehospital setting were identified. Our findings provide valuable insight and understanding of the challenges related to pain care prehospital providers face, in other similar prehospital settings, but also to the global body of knowledge on prehospital barriers and enablers of pain assessment and management.

The management of pediatric chronic pain in Spain: a web-based survey study

OBJECTIVE

To improve understanding of current practices in the treatment of children and adolescents with chronic pain in Spain.

METHODS

A web-based survey was conducted with a representative sample of healthcare professionals (i.e. general practitioners [GP] and pediatricians [P]) in Spain. The survey included 23 questions on the pain education and training they had been given, and on organizational issues and current practices in the assessment and management of children and adolescents with chronic pain in their current work.

RESULTS

The survey was completed by 191 professionals (75 GP and 116 P) with wide experience (mean number of years = 21; SD = 8) in the management of children and adolescents with chronic pain. Half of the participants reported that they had not been given any specific education or training on pediatric chronic pain management during their studies, and 80% acknowledged important gaps in their training. Although the majority assessed pain when attending children with chronic pain (80%), and almost all (96%) believed that protocols to guide the management of chronic pain in young people were necessary, only a third reported that they usually use a specific protocol. Less than 25% were part of a multidisciplinary team addressing the needs of children and adolescents with chronic pain.

CONCLUSIONS

This survey has identified considerable limitations in the management of children and adolescents with chronic pain in Spain. This information can now be used by policy makers to improve the care given to children and adolescents suffering from chronic pain and their families.

Prehospital acute traumatic pain assessment and management practices in the Western Cape, South Africa: a retrospective review

BACKGROUND

Trauma is a common aetiology of acute pain in the emergency setting, and traumatic injuries have been recognised as a global public health crisis leading to numerous deaths and disabilities. This study aimed to identify the prevalence of acute pain among high acuity trauma patients presenting to a public sector emergency medical service and to describe prehospital acute traumatic pain assessment and management practices amongst emergency care providers in the Western Cape Province, South Africa.

METHODS

A retrospective review of electronic patient care reports of trauma patients treated by the South African Western Cape Emergency Medical Services between January 1 and December 31, 2017 was conducted. Stratified random sampling was utilised to select 2401 trauma patients out of 24,575 that met the inclusion criteria.

RESULTS

Of the 2401 patients reviewed, 435 (18.1%) had a pain score recorded, of which 423 (97.2%) were experiencing pain. An additional 8.1% (n = 194) of patients had pain or tenderness mentioned in the working diagnosis but no pain score noted. Eighty-one (18.6%) patients experienced mild pain, 175 (40.2%) moderate pain and 167 (38.2%) severe pain. No association was found between a pain score recorded and age group (≤ 14 versus > 14 years) (p = 0.649) or gender (p = 0.139). Only 7.6% of patients with moderate-to-severe pain and 2.8% of all trauma patients received any form of analgesic medication. No association was found between the administration of analgesia and age group (≤ 14 versus > 14 years) (p = 0.151) or gender (p = 0.054). Patients were more likely to receive analgesia if they had a pain score recorded (p < 0.001), were managed by advanced life support practitioners (p < 0.001) or had severe pain (p = 0.001).

CONCLUSION

Acute trauma pain assessment and management practices in this prehospital cohort are less well established than reported elsewhere and whether this reflects emergency care training, institutional culture, scopes of practice or analgesic resources, requires further research. Emergency medical services need to monitor and promote quality pain care, enhance pain education and ensure that all levels of emergency care providers have access to analgesic medication approved for prehospital use. Clear and rational guidelines would enable better pain management by all cadres of providers, for all levels of pain.

Acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa: a knowledge, attitudes and practices survey

Background

Acute pain is frequently encountered in the prehospital setting, and therefore, a fundamental aspect of quality emergency care. Research has shown a positive association between healthcare providers’ knowledge of, and attitudes towards pain and pain management practices. This study aimed to describe the knowledge, attitudes, and practices of emergency care providers regarding acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa. The specific objectives were to, identify gaps in pain knowledge; assess attitudes regarding pain assessment and management; describe pain assessment and management behaviours and practices; and identify barriers to and enablers of pain care.

Methods

A web-based descriptive cross-sectional survey was conducted among emergency care providers of all qualifications, using a face-validated Knowledge, Attitudes and Practices of Pain survey.

Results

Responses of 100 participants were included in the analysis. The survey response rate could not be calculated. The mean age of respondents was 34.74 (SD 8.13) years and the mean years’ experience 10.02 (SD 6.47). Most respondents were male (69%), employed in the public/government sector (93%) as operational practitioners (85%) with 54% of respondents having attended medical education on pain care in the last 2 years. The mean percentage for knowledge and attitudes regarding pain among emergency care providers was 58.01% (SD 15.66) with gaps identified in various aspects of pain and pain care. Practitioners with higher qualifications, more years’ experience and those who did not attend medical education on pain, achieved higher scores. Alcohol and drug use by patients were the most selected barrier to pain care while the availability of higher qualified practitioners was the most selected enabler. When asked to record pain scores, practitioners were less inclined to assign scores which were self-reported by the patients in the case scenarios. The participant dropout rate was 35%.

Conclusion

Our results suggest that there is suboptimal knowledge and attitudes regarding pain among emergency care providers in the Western Cape, South Africa. Gaps in pain knowledge, attitudes and practices were identified. Some barriers and enablers of pain care in the South African prehospital setting were identified but further research is indicated.

What are the predictors, barriers and facilitators to effective management of acute pain in children by ambulance services? A mixed-methods systematic review protocol

Introduction

The management of pain is complex, especially in children, as age, developmental level, cognitive and communication skills and associated beliefs must be considered. Without effective pain treatment, children may suffer long-term changes in stress hormone responses and pain perception and are at risk of developing posttraumatic stress disorder. Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. The aim of this review is to identify predictors, barriers and facilitators to effective management of acute pain in children by ambulance services.

Methods

A mixed-methods approach has been adopted due to the research question lending itself to qualitative and quantitative inquiry. The segregated methodology will be used where quantitative and qualitative papers are synthesised separately, followed by mixed-methods synthesis (meta-integration). We will search from inception: MEDLINE, CINAHL and PsycINFO via EBSCOHost, EMBASE via Ovid SP, Web of Science and Scopus. The Cochrane Library, the Joanna Briggs Institute, PROSPERO, ISRCTN and ClinicalTrials.gov will be searched. We will include empirical qualitative and quantitative studies. We will exclude animal studies, reviews, audits, service evaluations, simulated studies, letters, Best Evidence Topics, case studies, self-efficacy studies, comments and abstracts. Two authors will perform full screening and selection, data extraction and quality assessment. GRADE and CERQual will determine the confidence in cumulative evidence.

Discussion

If confidence in the cumulative evidence is deemed Moderate, Low or Very Low, then this review will inform the development of a novel mixed-methods sequential explanatory study which aims to comprehensively identify predictors, barriers and facilitators to effective pain management of acute pain in children within ambulance services. Future research will be discussed among authors if confidence is deemed High.Systematic Review Registration: PROSPERO: CRD42017058960.

Benchmarking Pain Assessment Rate in Critical Care Transport

The purpose of this study is to determine the rate of pain assessment in pediatric neonatal critical care transport (PNCCT). The GAMUT database was interrogated for an 18-month period and excluded programs with less than 10% pediatric or neonatal patient contacts and less than 3 months of any metric data reporting during the study period. We hypothesized pain assessment during PNCCT is superior to prehospital pain assessment rates, although inferior to in-hospital rates. Sixty-two programs representing 104,445 patient contacts were analyzed. A total of 21,693 (20.8%) patients were reported to have a documented pain assessment. Subanalysis identified 17 of the 62 programs consistently reporting pain assessments. This group accounted for 24,599 patients and included 7,273 (29.6%) neonatal, 12,655 (51.5%) pediatric, and 4,664 (19.0%) adult patients. Among these programs, the benchmark rate of pain assessment was 90.0%. Our analysis shows a rate below emergency medical services and consistent with published hospital rates of pain assessment. Poor rates of tracking of this metric among participating programs was noted, suggesting an opportunity to investigate the barriers to documentation and reporting of pain assessments in PNCCT and a potential quality improvement initiative.