Reducing Time to Pain Medication Administration for Pediatric Patients with Long Bone Fractures in the Emergency Department

Impact of a Strategy for Improving Early Management of Acute Pain in the Pediatric Emergency Department

OBJECTIVES

The objective of this study was to measure the impact of an intervention on pain treatment in a pediatric emergency department (ED). The application of interventions to improve pain management in DE has demonstrated diverse effects so far, most of them successful.

METHODS

This is a quasi-experimental before-and-after, longitudinal, prospective study.Patients were collected between January 2020 and December 2021. Principal outcome was the number of patients with moderate or severe pain who received analgesia before 30 minutes to the ED arrival. The intervention consisted of several training sessions for nursing staff, pediatricians, and trauma physicians.

RESULTS

A total of 515 patients were enrolled, 230 during preintervention period and 285 during postintervention period. The percentage of patients receiving analgesia before 30 minutes increased from 24% to 29% and before 60 minutes increased from 31% to 42%. Time to analgesia administration decreased from 43 to 39 minutes.Only 254 patients (49%) received analgesia at some point during their stay in the ED, 137 (26.6%) before 30 minutes and 193 (37.5%) before 60 minutes. The probability of receiving analgesia was greater in patients seen by a pediatrician rather than an orthopedist (59%-37%). Metamizole was the most commonly used drug (48%), followed by ibuprofen and acetaminophen.

CONCLUSIONS

The application strategies to enhance early pain treatment in the ED can improve analgesia administration. Training strategies aimed at healthcare personnel working in the ED can change the way they work and achieve clear benefits for the patient. The treatment of pain in the ED should begin as soon as possible, and in this objective, the involvement of the nursing staff is a priority, because they are the professional who has the best opportunity for the detection and treatment of pain from the moment of triage.

Pain management of upper limb fractures in pediatric emergency department versus general orthopedics emergency department

Under treatment of pain is frequently reported in children even in conditions associated with severe pain such as fractures. Recent literature supports adequate and early pain treatment because extreme and uncontrolled pain can lead to hyperalgesia. Since 2017, the treatment of pediatric orthopedic cases in the "Meir" Medical Center was gradually shifted from the orthopedic general emergency department to the pediatric emergency department. The objective was to examine the differences in pain management between the orthopedic and pediatric emergency departments. Upper limb fractures were chosen as a representing case. This retrospective cohort study included children aged 0-18 years that suffered from an upper limb fracture and were admitted to the emergency department in the years 2016 and 2018. In our study, a total of 2520 children suffered from an upper limb fracture and were treated at the Meir Medical Center during the study period. 959 of these children were treated during 2016 in the general emergency department, and 1561 were treated in the pediatric emergency department during 2018. The group characteristics were similar. In the pediatric emergency department compared to general emergency department group, more children received analgesic treatment (47.85% versus 30.4%, p < .001), more opiates were given (13.9% versus 5.3%, p < .001), and the analgesic treatment was more adequate to pain severity. Additionally, sedation was performed more frequently in the pediatric emergency department (21.6% versus 9.5%, p < .001), especially for dislocated fractures (81.5% versus 31.4%, p < .001).

COMPLICATIONS

Length of stay, surgery, hospitalization, and recurrent referral rates were similar between the two groups.

CONCLUSIONS

 The transfer of orthopedic pediatric cases to the pediatric emergency department showed a notable improvement in pain management without an increase in complications or emergency department length of stay.

WHAT IS KNOWN

• Pain management and control is a major issue to address in their treatment. • Traumatic injuries and especially fractures are common causes for ED admissions.

WHAT IS NEW

• Comparing pain management and upper limb fractures treatment between general and pediatric ED. • Pain is better treated in the PED than in the GED, without an increased rate of complications.

The use of opioids in low acuity pediatric trauma patients

OBJECTIVE

To describe temporal trends and factors associated with opioid administration among children discharged from the emergency department (ED) after a trauma visit.

METHODS

This was a cross-sectional study of ED visits for children <19 years old who received a trauma-related diagnosis and were discharged from the ED. Data were obtained from the National Hospital Ambulatory Medical Care Survey 2006-2015.

OUTCOME MEASURES

Administration of an opioid medication either during the ED visit or as a discharge prescription. Survey-adjusted regression analyses were used to determine the probability of a patient receiving an opioid medication.

RESULTS

During the study period, there were 19,241 pediatric trauma visits discharged from the ED, of which 14% were associated with an opioid. Opioid administration decreased by nearly 30% during the study period (p<0.001 for trend). In multivariable analysis, patient factors associated with opioid administration were adolescent age, evening visit, region of the country, and severe pain score. The diagnosis associated with the most opioids was ankle sprain and the diagnosis with the highest rate of opioid administration was radius fracture. The most common opioid administered to children under 12 years of age was acetaminophen-codeine.

CONCLUSIONS

Opioid administration appears to be decreasing among pediatric patients presenting to the ED with trauma, but a high number of children continue to be exposed to opioids every year. Further education on opioid sparing pain management strategies may be warranted to decrease opioid exposure, including the inappropriate use of codeine, in this low risk trauma population.