Structures of paediatric pain management: a PERUKI service evaluation study

Abstract

BackgroundPain 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.ObjectiveTo benchmark current variation in assessment and management of childhood pain at network level.MethodsOnline 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.ResultsIn 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%).ConclusionDespite 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.

Pain management in children and young adults with minor injury in emergency departments in the UK and Ireland: a PERUKI service evaluation

“…This suggests a lack of uniform assertive ED pain management across the network, with the source issue likely to be related to knowledge translation and culture 2 6. A previous PERUKI study identified that training was included in induction/orientation in 24 sites (63%), professional development in 16 sites (42%), and pain/analgesia competencies were mandatory in 15 sites (39%),15 implying that pain education is a low priority for over 50% of responding institutions.…”

“…We have identified fundamental gaps in structures and processes that have resulted in the suboptimal outcomes. A strength of this study is that we have paired this study to the related structures 15. This study included patients aged from birth to 15 years (prior to their 16th birthday), with a range of nociceptive injuries, allowing for generalisable conclusions about pain practices for almost 4000 paediatric ED patient episodes related to minor injury.…”

“…The case report form and the accompanying guidance notes are available as online supplemental appendix 1. In parallel to the patient level data being collected a site survey was conducted 15…”

“…The structures related to paediatric pain are the physical and organisational characteristics where healthcare occurs and the processes are the actual steps involved in optimal analgesic practices (recognition of pain, assessment, intervention, reassessment and maintenance of pain relief). A previous PERUKI study identified high variation of pain management structures in the network 15. The foundation for improving quality of paediatric pain management should include the identification of gaps in our knowledge on pain related processes and outcomes.…”

The landscape of pediatric procedural sedation in UK & Irish emergency departments; a PERUKI study

“…A 2017 PERUKI survey, exploring structure supporting analgesic practices, described delivery of PPS in 13 (37%) of the 40 PERUKI member sites at the time. 13 In three years there has been a relative increase of 45%. However, despite wide use of PPS, we have found wide variability in agents and practices.…”