Australasian Emergency Nursing Journal (2012) 15, 133—147

Available online at www.sciencedirect.com

j our na l ho me p age: www.elsev ier .com/ locate /aenj

RESEARCH PAPER

Improving pain management of abdominal pain inchildren presenting to the paediatric emergencydepartment: A pre—post interventional studySuzanne Williams, MNSc (NP), BN (Hons), Grad Cert Paed Crit Care, Grad Cert Paed,Chld & Yth Hlth Nrsing, RN, NP, B. Health Sc (Nursing) a,∗Kerri Holzhauser, RN, BHealth Sc (Nrsg) b,c

Donna Bonney, RN, BN, MN, Grad Cert Emerg d

Elizabeth Burmeister, MSc (Biostatistics), BN, DipNurs b

Yuri Gilhotra, MBBS, FACEM a

Randall Oliver, RN, BN a

Kerry Gordon, RN, NP, MNSc (NP), BN (Hons) a

a Mater Children’s Hospital Emergency Department, Brisbane, Australiab Princess Alexandra Hospital, Brisbane, Australiac Griffith University Research Centre for Clinical and Community Practice Innovation, Brisbane, Australiad Mater Health Services, Brisbane, Australia

Received 6 September 2011; received in revised form 18 April 2012; accepted 18 April 2012

KEYWORDSAbdominal pain;Child;Paediatric;Pain management;

SummaryBackground: In 2007, the Mater Children’s Hospital Emergency Department participated in theEmergency Care Pain Management Initiative funded by the National Health and Medical ResearchCouncil National Institute of Clinical Studies (NHMRC — NICS). The findings of this NHMRC — NICSresearch across eleven paediatric emergency departments highlighted deficits in pain man-

Analgesia; agement of abdominal pain. Specifically pain assessment, timeliness of analgesia, and painre found to be lacking.

Pain assessment; management guidelines we

Emergencydepartment

Methods: In response to the NICS report local practice was reviewed and a pilot research projectundertaken to develop a clinical guideline for the pain management of abdominal pain in chil-dren presenting to the emergency department. The guideline was developed by an expert paneland trialled using a pre and post intervention design.

∗ Corresponding author at: Mater Children’s Hospital Emergency Department, Raymond Terrace, South Brisbane 4001, Brisbane,Australia. Tel.: +61 07 3163 6337; fax: +61 07 3163 8744.

E-mail address: Suzanne.williams@mater.org.au (S. Williams).

1574-6267/$ — see front matter © 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.aenj.2012.04.003

134 S. Williams et al.

Results: The results demonstrated improved compliance to assessment and documentation ofpain scores and assimilation of the best practice principles recommended in the guideline.Conclusions: This project raised local awareness in the pain management of abdominalpain and provides baseline information for future improvement. The guideline has been tri-alled in the clinical setting of paediatric emergency and has the potential to improve painmanagement practices in children presenting to the emergency department with abdominalpain.

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© 2012 College of Emergenreserved.

What is known

• The literature suggests that pain managementof abdominal pain in children presenting to theemergency department is poorly managed. Earlyadministration of analgesia does not mask signs of anacute abdomen. However this is not well understoodand presents a significant barrier to appropriate painmanagement of children presenting to the emer-gency department. Furthermore time to analgesiain this patient group is often delayed and falls out-side the NICS NHMRC recommendation of analgesiawithin 30 min of triage.

What this paper adds

• This paper describes the introduction of an evi-dence based guideline to support pain managementof abdominal pain in children. The guideline wastrialled using a pre—post interventional study. Clin-ical findings demonstrated an improvement in painassessment and documentation and improved knowl-edge of nursing and medical staff in regard to painmanagement. This research provides a basis forfuture improvement in pain management practices.

ntroduction

bdominal pain is one of the most common symp-oms reported in the paediatric population presentingo the emergency department (ED).1 However, childrenith abdominal pain do not routinely receive timely orppropriate analgesia in this setting.1 Children’s pain isften inadequately treated affecting the child’s abilityo cope and causing feelings of helplessness, fear andnxiety.2

In 2007 the Mater Children’s Hospital Emergency Depart-ent (MCH ED) participated in the Emergency Care Painanagement Initiative funded by the National Health andedical Research Council — National Institute of Clinicaltudies (NHMRC — NICS). This initiative included a ret-ospective chart audit to investigate pain managementf abdominal pain, migraine and fractured femur.3 Tenajor paediatric Australian and New Zealand departments,

embers of the Paediatric Research in Emergency Depart-ents International Collaborative (PREDICT), participated

n the audit.4 The findings across the paediatric peer groupevealed only 62% of children with abdominal pain received

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nalgesia in the emergency department (ED).3 The medianime to analgesia (from arrival in ED) for the abdominal painohort was 1.71 hours at MCHED compared to 1.20 hourscross the peer group.3 A sub-analysis of the data extractedor the NICS study identified that of the 20 patients includedn the audit at MCHED, only 15% (n = 3) received analge-ia within 30 min of triage in line with the national targetecommended by NICS.3,5 Other common deficits were iden-ified in the general standard of practice across the healthervices in comparison to the current pain managementecommendations by the NHMRC. Areas of particular notencluded documentation of pain assessment, time to anal-esia, reporting systems to monitor pain performance andeedback to staff, pain management guidelines and otherarriers such as time, knowledge, resources and pre-existingisconceptions amongst doctors and nurses.3 In summary

he findings and recommendations of the NICS Collabora-ive Pilot Study correlate with the Royal Australasian Collegef Physicians Guideline Statement on paediatric pain man-gement that clinical practice does not consistently reflectvidence-based practice.2

In light of the NICS report, current local practice waseviewed in 2008 prompting a search for industry guide-ines. The absence of current paediatric guidelines provided

driver amongst staff at the MCH ED to develop an evidence-ased guideline to facilitate the appropriate managementf pain in children presenting to the Emergency Depart-ent (ED) with abdominal pain. A pilot research project waseveloped based on the findings of the NICS study. Primaryoals included early administration of appropriate analge-ia and timely, objective pain assessment. Approval for theroject was granted by the Mater Human Research and Ethicsommittee and funding provided by a Queensland Healthursing and Midwifery Novice Research Grant. This projectulminated in the development of evidence based guidelinend best practice principles for the management of painn children presenting to the emergency department withbdominal pain. This guideline has been successfully triallednd implemented locally and is available for use by nursingnd medical staff in the ED.

eview of the literature

review of the literature was undertaken in March 2008

uideline addressing the pain management aspect of car-ng for children with abdominal pain in emergency. Studieshat were included in the systematic review adhered to theollowing inclusion criteria:

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Pain management of children with abdominal pain

• The study focused on pain management of abdominalpain

• The setting of the study was the emergency department• Study participants were children aged 0—18 years• The study was available in English

An initial search for existing clinical guidelines wasconducted and included the National Clearinghouse, theNational Health and Medical Research Council, Royal Chil-dren’s Melbourne Clinical Practice guidelines, New SouthWales Health Clinical Practice Guidelines, National Insti-tute of Clinical Evidence (UK), Therapeutic Guidelines Inc.,Medline Plus, Up to Date, Joanna Briggs Institute, CochraneLibrary, Australian and New Zealand College of Anaesthetistsand Faculty of Pain Medicine and Queensland Health Clin-ical Guidelines. The search did not reveal any existingguidelines which specifically addressed pain management ofchildren with abdominal pain presenting to the emergencydepartment.

A comprehensive search strategy was subsequentlydesigned using the following Medical Subject Head-ings (MeSH) with explosion of key words: abdomen,acute/diagnosis; acute/drug therapy; abdominal pain ANDacute; child or adolescent; analgesia OR analgesic agent;and emergency/medicine/nursing/hospital.

Limiters narrowed the search to children 0—18 yearsand studies available in English. This search was initi-ated in Cinahl, Medline plus and Embase and yielded 114papers. Abstracts of included studies were retrieved andassessed for eligibility according to the inclusion criteria.The titles of these papers were assessed independently bytwo researchers. Scrutiny of the research abstracts deter-mined which studies related to children, described theemergency department setting and focused on the pain man-agement of abdominal pain. This selection process yielded30 papers which were read independently by two review-ers. If the paper met the inclusion criteria or if eligibilitywas unclear, the full text of the article was retrieved.Of these 30 papers twenty were excluded because oncloser inspection they were found to be editorials, com-mentaries, were not set in the emergency departmentand/or referred to adult patients. The final ten paperswere critically reviewed by three independent reviewersutilising a data extraction sheet and scoring process.6,7

Review items included abstract and title, introduction andaims, theoretical framework, method and data, sampling,data analysis, ethics and bias, results, transferability orgeneralisability, implications and usefulness. Each itemattracted a possible highest score of 4, with a maximumtotal of 40 points. Based on the numeric score a rank-ing was applied from very poor to very good. All paperseligible for selection scored greater than 25 points or aranking of fair to very good. This literature provided thefoundation upon which the guideline and algorithm wasdeveloped.

A search of the literature was repeated in June, 2010 atthe time of data analysis to determine if any other relevantstudies had been published since development of the algo-

rithm. A single study was found which supported the findingsof the initial systematic review however did not add any newinformation. This study has been included in the supportingreferences.

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135

ummary of the literature

eview of the literature did not yield specific paediatricuidelines for pain management of abdominal pain in chil-ren presenting to emergency. Much of the research reflectsn adult focus of current evidence with few clinical trialsxamining paediatric practice.

Abdominal pain is one of the most common symptomsriggering paediatric presentation to emergency.1 Gold-an, Narula, Klein-Kremer and Rogovik report as few

s 9% of children presenting to emergency with acutebdominal pain receive opioid analgesia despite subse-uently requiring abdominal surgery as a result of theirresentation.1 Goldman, Crum, Bromberg, Rogovik andanger report only 50% of children with a high clinicalndex for appendicitis received analgesia. Only a minor-ty of these children received opioids.8 Myths such as‘children do not feel or remember pain’’ and ‘‘treatingain masks underlying symptoms’’ continue to influencelinical decisions in regard to paediatric pain management.linicians sometimes withhold analgesia from paediatricatients with acute abdominal pain due to concerns thatain medication could mask or alter physical signs andymptoms, making diagnosis more difficult.8—18 Further-ore, if opioids are prescribed for abdominal pain in

hildren it is frequently at a sub-clinical dose.1 Such prac-ices continue in contradiction to current evidence.1—5,8—18

dministering morphine in an appropriate dose to childrenith abdominal pain results in a significant reduction of

heir pain without any significant difference in diagnosticccuracy.1—3,8—16

A number of barriers to administration of analgesia inhe emergency department are commonly identified in theiterature. These include tradition, culture, experience ofhe clinician, lack of knowledge in regard to effect ofnalgesia, fear of addiction and absence of clinical guide-ines and leadership.15 Other influences in pain managementnclude attitudes and practices of senior clinicians. Goldmant al. reported that some ED physicians withheld analge-ia in deference to the paediatric surgeon’s disapproval ofhe administration of analgesia to children with abdominalain.8

The literature describes specific strategies to addressarriers to appropriate pain management.15 Use ofn age appropriate pain assessment tool facilitatesccurate assessment and documentation of paediatricain.4 Initiation of pain assessment and management atriage by nurses was commonly identified as a key toarly and effective pain management in the emergencyepartment.1,8 This strategy is further enhanced by these of protocols supporting nurse initiated analgesia.ocumentation of pain scores during clinical assessmentf children improves pain management.1,8 Appropriatenalgesia is more likely to be administered if theres a protocol or guideline to support use, especiallyn the case of opioids.5,8 Staff education and sup-ort is recommended to develop pain assessment skills

1,5

nd effective prescribing practices. Evidence basedain management guidelines and pain assessment toolsre not routinely implemented in paediatric emergencyractice.2

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36

ethods

n response to the NICS report current local practice waseviewed in 2008 and a pilot research project undertakeno develop and introduce a clinical guideline for the painanagement of abdominal pain in children presenting to the

mergency department.

ypotheses and specific aims of the study

ntroduction of a guideline for pain management of abdomi-al pain in children presenting to the emergency departmentill:

. Improve documentation of pain score on assessment ofpain at triage

. Increase the proportion of children with abdominal painreceiving analgesia within 30 min by 20% to a minimum of35% in comparison to the NICS pilot study result of 15%.

. Improve the knowledge of nursing and medical staff inregard to pain management

. Assist in identifying barriers to pain management

etting

ater Children’s Paediatric Emergency Department is a ter-iary referral centre currently treating more than 47,000resentations of children aged 0—16 years per annum. TheCH ED services the Brisbane South population 24 h per day

or acutely ill or injured children. As one of two tertiaryaediatric Emergency Services in Queensland and as the Pae-iatric Trauma Centre for Brisbane South, the departmenteceives transfers from regional hospitals and northern Newouth Wales.

Of 39,000 presentations at MCHED in 2007, approximately.2% were diagnosed with abdominal pain, which equates topproximately 72 presentations per month.

tudy design

he study used a pre-test post-test intervention design.he intervention consisted of the development and intro-uction of an evidence-based paediatric pain managementuideline. A staff survey on attitudes to pain managementnformed development of the guideline and provided a baseine upon which to measure changes in attitudes after theuideline had been introduced. Retrospective pre and posthart audits using the NICS audit tool enabled comparison ofractice before and after introduction of the guideline.

evelopment of the guideline

systematic review of the literature, NICS data and surveyesults informed initial development of a draft guideline.he guideline focuses on analgesia to manage abdominal

ain and does not include adjuncts to abdominal pain man-gement such as antacids, anti-emetics, antispasmodics andperients. An expert panel was convened to review the draftnd further develop the guideline. The panel included two

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S. Williams et al.

aediatric emergency specialists, a clinical nurse consul-ant, two nurse educators, a senior paediatric pharmacist, aepresentative of the National Institute of Clinical Studies, aenior research adviser and a nurse practitioner. One of theurse educators is affiliated with a tertiary paediatric acuteare facility in Brisbane, and, the remaining clinicians areffiliated with Mater Children’s Hospital. The senior researchdvisor is affiliated with a tertiary adult health care facil-ty in Brisbane. The opinions of panel members associatedith official government agencies represent their views andot necessarily those of the agency of which they are affil-ated. Development of the guideline was completed withinix months from July to December, 2008 and reviewed inugust 2011.

taff survey

staff survey was administered before and after the intro-uction of the guideline. Participation in the survey wasoluntary and anonymous and offered to medical and nursingtaff. The purpose of the survey was to examine attitudesnd barriers to pain management of abdominal pain andnform development of the guideline and subsequent edu-ation sessions. The survey was adapted from a pain surveyreviously developed for paediatric nurses by Manworrennd approved by the Mater HREC.19 Content validity estab-ished by the expert panel by a review of current questionsor language and relevance to the Australian setting andhe objectives of the project. The survey was piloted on

small number of paediatric nurses of varying levels ofxperience. Internal reliability was established using Kuder-ichardson co-efficient (KR-20), a co-efficient alpha formulased specifically for dichotomous variables.20 The KR-20 wasalculated based on 64 responses and reliability was 0.90.

To maintain confidentiality, surveys were placed in eachtaff mailbox with a letter of explanation and a sealedepository provided in a staff area. Surveys were collectedrom the depository after two weeks. Results from the surveyere used to inform the education strategy and develop-ent of the paediatric pain management guideline. The

urvey was re-administered one month after the guidelinerial was completed to measure changes in knowledge andttitudes in the wake of the education sessions and imple-entation of the guideline.

opulation, sample size and data collection

or the purpose of the retrospective chart audits, the pop-lation included all paediatric presentations (aged two toixteen years) with a diagnosis of abdominal pain. As in theICS study the Emergency Department Information systemEDIS) was used to identify this population which includedhe following ICD10 codes: R10.0 — abdominal pelvic pain;10.1 — pain localised upper abdomen; R10.2 — pelvic anderineal pain; R10.3 — pain localised to other parts ofbdomen; R10.4 — other and unspecified abdominal pain;30.9 — pain micturition unspecified; R30.0 — pain associ-

ted with micturition.

Sample size for the chart audits was calculated using pilotata from the NICS pain initiative audit. Approximately 15%f the NICS population (MCHED cohort) received analgesia

137

Table 1 Diagnosis of patients ICD-10 codes — pre and postintervention audit.

ICD-10 Name Pre, n (%) Post, n (%)

R10.0 Abdominal pelvic pain 13 (16.1) 9 (11.3)R10.1 Pain localised upper

abdomen14 (17.5) 17 (21.3)

R10.2 Pelvic and perinealpain

0 1 (1.3)

R10.3 Pain localised toother parts of theabdomen

48(60) 52(65)

R30.9 Pain micturitionunspecified

5 (6.3) 1 (1.3)

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Hey Triage Pain Score in the triage assessment by the triagenurse at the time of triage.21 A significant difference wasfound in pain score documentation pre and post intervention(Table 3).

Table 2 Pain score at triage.

Was the pain score documented?

Yes No

Pain management of children with abdominal pain

within the national target timeframe of 30 min. The MCH EDstudy aimed to increase the proportion of children receivinganalgesia within 30 min by at least 20—35% following imple-mentation of abdominal pain management guidelines. Thesample size calculated to detect an increase by 20—35% was80 in both pre and post intervention groups assuming a base-line percentage of 15%, type I error of 0.05 (95% confidenceinterval) and power of 85%. The sample was selected basedon presentations with the nominated EDIS codes over twomonths and randomised for the purpose of the pre and postinterventional audits. Retrospective data was collected inthe two months before and after trial of the guideline. Datacollection was based on the method developed in the NICSstudy and facilitated with a modification of the NHMRC NICSpain initiative data collection tool.18

Introduction of the guideline

Introduction of the guideline was achieved through a varietyof media including email, electronic noticeboard, educationsessions with PowerPoint presentations and poster displaysin work areas. The education session presented a synopsis ofthe research project, summary of the findings from the NICSNHMRC pilot study, education regarding pain managementprinciples and general discussion time to explore staff per-ceptions in relation to pain management. It also provided anopportunity to discuss misconceptions identified in the sur-vey. A trial of the guideline commenced for 6-month periodfrom March 2009.

Data analysis

Data was collected using an access database and statisticalanalysis performed using STATA: Data Analysis and StatisticalSoftware. Differences before and after implementation ofthe abdominal pain management guidelines were analysedusing non parametric tests for continuous data including painscores and time to analgesia. Chi-squared test and relativerisk were used to analyse the dichotomous outcome of dif-ference in the proportions of children receiving analgesia by30 min before and after the intervention. Demographic dataanalysis used t-tests.

Ethical considerations

The project was approved by the Mater Health ServicesHuman Research and Ethics Committee (HREC). Charts wererandomised using patient record numbers. The data collec-tion was de-identified with allocation of sample numbers1—80 to each record. A code sheet to enable data checkingwas created to link the coded data to the identified data.This was stored in a secure location accessible by the datacollection team separate to the raw data.

Results

The following tables describe age, gender, diagnosis of thepopulation in both pre and post test samples. There was nosignificant difference found in any of these variables.

Total 80 80

No significant difference, p = 0.304 (chi square).

emographics

he mean age of patients was 8.9625 (SD 4.064) prior tontervention and 8.425 (SD 3.897) after the intervention.here was no statistical difference p = 0.39 (t-test). The gen-er of the sample was 53.8% pre-test male and 42.5% postest with no statistical difference between the two timeoints difference p = 0.154 (chi square).

The majority of diagnoses were pain localised to otherarts of abdomen R10.3 (n = 48 pre and 52 post). Other diag-oses include R10.0 — abdominal pelvic pain; R10.1 — painocalised upper abdomen; R10.2 — pelvic and perineal pain;nd R30.9 — pain micturition unspecified (Table 1).

Data reported in the following tables includes documen-ation of pain score, reassessment of pain score, time tonalgesia and percentage of patients receiving analgesiaithin 30 min. The time to analgesia specifically reports time

rom triage to receiving analgesia if there was no analgesiaiven at home or in the ambulance.

ocumentation of pain score

he pain score predominately used at MCHED is the Alderey Triage Pain score observational pain scoring tool. Thisool has been validated for use in children presenting tomergency.21 Staff are introduced and educated in the usef this pain score during orientation to the departmentTable 2).

Pain score at triage refers to documentation of an Alder

Pre 25 31.25 55 68.75Post 38 47.50 42 52.50

Significant difference, p = 0.035 (chi square).

138

Table 3 Reassessment of pain score.

Was the pain score reassessed?

Yes No

Pre 6 7.4 20 25.0Post 9 11.25 21 26.25

No significant difference, p = 0.56 (chi square).

Table 4 Time to analgesia (no analgesia given prior topresentation).

Pre (min), n = 80 Post (min), n = 79

Mean 18.8 29.9Median 10.5 12.0Interquartile range 8, 49 6, 48

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No significant difference, p = 0.57.

Reassessment of pain score refers to documentation of anlder Hey Triage Pain Score in the patient observation chartfter the first documented pain score or administration ofnalgesia whilst in the emergency department.21

ime to analgesia from triage

ime to analgesia was defined as number of minutes elapsedrom time of triage to administration of any analgesia by anyoute. Children who received analgesia pre hospital at homer on route were excluded. There was an improvement inoth pre (92.5 min) and post (91 min) test medians in com-arison to the NICS data with a median of 103 min.3 Howeverhere was no significant improvement in time to analgesiaetween the pre and post intervention data (Table 4).

nalgesia within 30 min of triage

here was a small increase in the post intervention data by.4% of children receiving analgesia within 30 min of triage.he pre-intervention baseline data was improved by 37.8% inomparison to the NICs data.3 Children who received anal-esia prior to triage (at home or in the ambulance) werexcluded (Table 5).

uideline

his guideline describes pain management recommenda-

ions for children presenting to emergency with abdominalain and includes evidence based best practice principlesnd an algorithm guiding choice of analgesia based on paincore (Fig. 1).

Table 5 Percentage of children receiving analgesia within30 min of registration.

NICS audit 15%Pre audit, n = 28 64.3%Post audit, n = 27 66.7%

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S. Williams et al.

urvey

f the seventy surveys that were delivered to participants7 surveys (52.8%) were returned pre intervention and 2738.5%) surveys post intervention. The pre-survey omitted toollect designation of the participant. The post survey wasompleted by seventeen nurses, one doctor and nine undes-gnated participants. The data collected from the pre-surveyas analysed to inform the education strategy by focusingn identified knowledge deficits.

Overall survey results demonstrated a significantmprovement in the number of correct answers for theajority of questions as demonstrated in Table 6 . Each sur-

ey was marked and out of a score of 36, scores ranged from minimum of 7 to a maximum of 18, median score of 13 (IQR1, 14) in the pre-test and a minimum of 17 to a maximumf 33, median score of 29 (IQR 26, 30) in the post-test. Usingann—Whitney Test for two independent samples there was

tatistical significant difference of p = 0.000.

imitations

here were several limitations to this study. During the timehe trial was implemented there was a large turnover ofursing and medical staff, which was challenging in regardo initiation to the guideline. Education sessions were wellttended by approximately 85% of nursing staff and poorlyttended by medical staff possibly due to the times the ses-ions were held. The education sessions were not continuedhroughout the trial; however the guideline was includedn training at triage workshops attended by nursing staff.ecently the guideline has also been added to the orienta-ion package for new nursing staff, which, it is anticipatedill enhance uptake. All staff (nursing and medical) were

ent regular information emails throughout the course ofhe trial with the guideline attached to promote use. Theepartment electronic notice board was also used to pro-ote the guideline.When collecting data it was observed that ‘‘0’’ was rarely

sed to indicate no pain. In this situation the triage nurseore commonly describes the child as ‘‘happy and playing’’

r ‘‘pain free’’. These observations were not treated as aain score within the data collection for both pre and postata collection. Recording of a ‘‘0’’ pain score is necessaryo provide a baseline observation upon which to measurelinical progression and this finding will be integrated intouture pain score training.

Compliance to survey participation was 52.8% pre audit,owever only 38.6% of surveys were returned post audit.ue to an error on the survey form participants were notifferentiated as medical or nursing in the pre audit survey,pproximately 70% of the post audit surveys were completedy nursing staff.

Development of the guideline was facilitated by anxpert panel of paediatric health experts; however chil-ren and parents were not represented. All but one memberf the expert panel were from Mater Children’s Hospital as

nvitations for external recruitment to the expert panel hadimited success. The content of the guideline addresses anal-esia however does not include adjuncts such as antacids,ntispasmodics, antiemetics or aperients. Inclusion of these

Pain m

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139

Figure 1 Guideline for pain management of abdominal pain in children.

140 S. Williams et al.

Table 6 Survey results.

Question Correctresponse

% Correctpre, n = 37

% Correctpost, n = 27

Improvement p value (chi square)

1. Observable changes in vitalsigns must be relied upon toverify a child’s/adolescent’sstatement that he has severepain.

False 10.8 88.9 78.1% 0.000

2. Because of anunderdeveloped neurologicalsystem, children under2 years of age havedecreased pain sensitivityand limited memory ofpainful experiences

False 8.1 92.6 84.5% 0.000

3. If the infant/child/adolescent can be distractedfrom his pain this usuallymeans that he is notexperiencing a high level ofpain.

False 21.6 74.1 52.5% 0.000

4. Infants/children/adolescents may sleep inspite of severe pain.

True 35.1 81.5 46.4% 0.000

5. Comparable stimuli indifferent people produce thesame intensity of pain

False 0 96.3 96.3% 0.000

6. Non-drug interventions (e.g.heat, music, imagery, etc.)are very effective formild—moderate pain control,but are rarely helpful formore severe pain.

False 67.6 33.3 −34.3% 0.007

7. Children who will requirerepeated painful procedures(e.g. venepuncture), shouldreceive maximum treatmentfor the pain and anxiety ofthe first procedure tominimise the development ofanticipatory anxiety beforesubsequent procedures.

True 13.5 92.6 83.1% 0.000

8. Respiratory depressionrarely occurs inchildren/adolescents whoreceive opioids

True 78.4 25.9 −52.5% 0.000

9. Paracetamol 650 mg PO isapproximately equal inanalgesic effect to codeine32 mg PO.

True 91.9 7.4 −84.5% 0.000

10. The World HealthOrganization (WHO) painladder suggests using singleanalgesic agents rather thancombining classes of drugs(i.e. Combining an opioidwith a non-steroidal agent).

False 19.4 96.2 76.8% 0.000

11. The usual duration ofanalgesia of morphine IV is4—5 h.

False 18.9 85.2 66.3% 0.000

Pain management of children with abdominal pain 141

Table 6 (Continued)

Question Correctresponse

% Correctpre, n = 37

% Correctpost, n = 27

Improvement p value (chi square)

12. Parents should not bepresent during painfulprocedures.

False 0 96.3 96.3% 0.000

13. Adolescents with a historyof substance abuse shouldnot be given opioids for painbecause they are at high riskfrom repeated addiction.

False 2.7 100 97.3% 0.000

14. Beyond a certain dosage ofmorphine increases indosage will NOT provideincreased pain relief.

False 35.1 70.4 35.3% 0.005

15. Young infants, less than6 months of age, cannottolerate opioids for painrelief.

False 10.8 92.6 81.8% 0.000

16. The child/adolescent withpain should be encouragedto endure as much pain aspossible before resorting to apain relief measure.

False 0 100 100% 0.000

17. Children, less than 8 years,cannot reliably report painintensity and therefore, thenurse should rely on theparents’ assessment of thechild’s pain intensity.

False 16.2 84.6 68.4% 0.000

18. Based on one’s religiousbeliefs a child/adolescentmay think that pain andsuffering is necessary

True 32.4 73.1 40.7% 0.001

19. Anxiolytics, sedatives, andbarbiturates are appropriatemedications for the relief ofpain during painfulprocedures

False 27.0 59.3 32.3% 0.010

20. After the initialrecommended dose of opioidanalgesic, subsequent dosesshould be adjusted inaccordance with theindividual patient’sresponse.

True 13.5 96.3 82.8% 0.000

21. The child/adolescentshould be advised to usenon-drug techniques alonerather than concurrentlywith pain medications.

False 5.4 92.6 87.2% 0.000

22. Giving children/adolescents a placebo isoften a useful test todetermine if the pain is real.

False 0 100 100% 0.000

23. In order to be effective,heat and cold should beapplied directly to thepainful area.

False 21.3 70.4 49.1% 0.000

142 S. Williams et al.

Table 6 (Continued)

Question Correctresponse

% Correctpre, n = 37

% Correctpost, n = 27

Improvement p value (chi square)

24. Analgesia cannot beadministered to childrenwith suspected appendicitisbefore review by the surgicalteam.

False 0 100 100% 0.000

25. Oral analgesia can be givento children with suspectedappendicitis at any time.

True 32.4 85.2 53.1% 0.000

26. Analgesia should beoffered in the order ofweakest drug to strongestdrug and titrated until painhas been treated.

False 13.5 77.8 64.3% 0.000

27. Pain is more likely to beeffectively managed in thepaediatric patient if a painscore is utilised

True 89.2 7.4 81.8% 0.000

Multiple choice Correctresponse

% Correctpre, n = 37

% Correctpost, n = 27

Improvement p value (chi square)

i. The recommended routeof administration of opioidanalgesics to children withbrief, severe pain of suddenonset, e.g. trauma orpostoperative pain, is:

A 97.2 100 2.8% 0.383

a. Intravenousb. Intramuscularc. Subcutaneousd. Orale. Rectalf. I don’t know

ii. Which of the following IVdoses of morphineadministered would beequivalent to 15 mg of oralmorphine?

B 43.8 52.2 8.4% 0.537

a. Morphine 3 mg IVb. Morphine 5 mg IVc. Morphine 10 mg IVd. Morphine 15 mg IV

iii. Analgesics forpost-operative pain shouldinitially be given:

A 94.4 92.6 −1.8% 0.765

a. Around the clock on afixed schedule

b. Only when thechild/adolescent asks for themedication

c. Only when the nursedetermines that thechild/adolescent hasmoderate or greaterdiscomfortiv. Analgesia for chronic painshould be given:

A 81.1 74.1 −7.0% 0.503

Pain management of children with abdominal pain 143

Table 6 (Continued)

Multiple choice Correctresponse

% Correctpre, n = 37

% Correctpost, n = 27

Improvement p value (chi square)

a. Around the clock on afixed schedule

b. Only when thechild/adolescent asks for themedication only when thenurse determines that thechild/adolescent hasmoderate or greaterdiscomfortv. The most likelyexplanation for why achild/adolescent with painwould request increaseddoses or pain medication is:

A 100 100 0

a. The child/adolescent isexperiencing increased pain

b. The child/adolescent isexperiencing increasedanxiety or depression

c. The child/adolescent isrequesting more staffattention

d. The child/adolescent’srequests are related toaddictionvi. The most accurate judgeof the intensity of thechild’s/adolescent’s pain is:

C 86.5 96.0 9.5% 0.214

a. The treating physicianb. The child’s/adolescent’s

primary nursec. The child/adolescentd. The pharmaciste. The child’s/adolescent’s

parentvii. Which of the followingdescribes the best approachfor cultural considerations incaring for child/adolescentpain?

C 0 96.2 96.2% 0.000

a. Because of the diverseand mixed cultures inAustralia, there are nolonger cultural influences onthe pain experience.

b. Nurses should useknowledge that has definedclearly the influence of painon

c. Children/Adolescentsshould be individuallyassessed to determinecultural influences on pain.

144 S. Williams et al.

Table 6 (Continued)

Multiple choice Correctresponse

% Correctpre, n = 37

% Correctpost, n = 27

Improvement p value (chi square)

viii. What do you think is thepercentage of patients whoover report the amount ofpain they have? Circle thecorrect answer (correctanswer is underlined)0 or 10% 20% 30% 40%50% 60% 70% 80% 90%100%

A 54.1 40.7 −13.4% 0.293

ix. Narcotic/opioid addictionis defined as psychologicaldependence accompanied byoverwhelming concern withobtaining and using narcoticsfor psychic effect, not formedical reasons. It mayoccur with or without thephysiological changes oftolerance to analgesia andphysical dependence(withdrawal). Using thisdefinition, how likely is itthat opioid addiction willoccur as a result if treatingpain with opioid analgesics?Circle the correct answer.<1% 5% 25% 50% 75%100%

78.4 96.3 17.9% 0.042

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djuncts was discussed at length by the research team andmitted as a more thorough assessment is required prioro prescription of these medications. Distraction has beenncluded as an adjunct to analgesia but training in distrac-ion was not provided to nursing or medical staff.

iscussion

evelopment of this guideline has been driven by the goalo reduce pain experienced by children presenting to themergency department. This is significant for a numberf reasons. Inappropriate management of pain can leado increased levels of pain experienced by children duringubsequent treatments as anxiety; distress, anger and emo-ional turmoil contribute to heightened pain perception.22

ainful experiences in hospital during childhood significantlympact on the child’s future health behaviours manifestingn doctor phobias and avoidance of medical experiences andettings and contributing to poor health outcomes.2,22—26

This guideline represents the first step in improving painanagement of abdominal pain in children presenting to

mergency. Paediatric abdominal pain presentations span broad range of illnesses which arise from both medi-al and surgical aetiology. Consequently, approach to painanagement requires a range of analgesia which will treat

popt

he acuity of the pain. This is evident in the algorithm, whicheflects the World Health Organisation (WHO) pain ladderpproach, matching pain score to analgesia.27 The algorithmocuses on pharmacological pain management in conjunc-ion with distraction and does not address the use of otheron-pharmacological adjuncts.

The algorithm is underpinned by the six best practicerinciples presented in the guideline which translate cur-ent evidence into practice. Key to these principles is prend post pain documentation and initiation of analgesia atriage, practices which have been show to improve painanagement.8,9 The recommended medications listed in the

lgorithm do not include non-steroidal anti-inflammatoryedication because these medications are contra-indicated

or abdominal pain.9 It should also be noted that the usef codeine has not been advocated in the guideline as effi-acy is variable between individuals, with possibly 50% ofhildren falling within this category.9 Distraction therapys recommended as a non-pharmacological intervention asn adjunctive to all pharmacological therapies as it haseen found to reduce the stress and pain experiencedy the paediatric patient especially in regard to painful

23—26

rocedures. The effectiveness of distraction in isolationr as an adjunct to pharmacological measures during anyotentially painful procedures is extensively documented inhe literature.23—26,28—31

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Pain management of children with abdominal pain

The primary aims of the study were to:

- improve documentation of pre and post analgesia painscore on assessment of pain at triage

- increase the proportion of children with abdominal painreceiving analgesia within 30 min by 20% to a minimum of35% in comparison to the NICS pilot study result of 15%.

- improve the knowledge of nursing and medical staff inregard to pain management

- identify barriers to pain management

Three of the four study aims were achieved. The find-ings revealed a significant improvement in pain assessmentand documentation of pain score at triage. It is unclear ifthis improvement can be attributed to the introduction ofthe guideline or to the education sessions. Improvement instaff knowledge was demonstrated in 27 of the 36 pain sur-vey questions despite staff turnover. Several barriers to painmanagement were identified in the survey results includ-ing inadequate understanding of the use of distraction inpaediatric pain management. The proportion of childrenreceiving analgesia within 30 min of triage was not increasedby 20% after the guideline was introduced. However, whenthe pre-test data was collected the proportion of childrenreceiving analgesia within 30 min of triage was measuredat 64.3%, an improvement on the NICS baseline of 49.7%.The post-test improved marginally to 66.7% demonstratingno statistical significance despite introduction of the guide-line. The driver for the significant improvement betweenthe NICS and pre-test time to analgesia could be attributedto increased clinician awareness through dissemination anddiscussion of the NICS results prior to commencement of thisstudy.

The pre audit survey informed both the developmentof the guideline and preparatory education sessions. Thepost intervention survey results demonstrate assimilationof many of the best practice principles recommended inthe guideline. Improvement in staff knowledge was demon-strated in 27 of the 36 questions despite staff turnover. Thisimprovement was supported by education sessions and expo-sure and access to the guideline during the implementationphase. One of the drivers motivating development of theguideline was the practice of some clinicians of withhold-ing analgesia prior to surgical review in children with acuteabdominal pain. Subsequently the following statement waspresented in the survey: Analgesia cannot be administeredto children with suspected appendicitis before review bythe surgical team. In the pre intervention survey no partici-pants responded correctly to this statement; whereas in thepost survey 100% of participants accurately identified thisstatement to be false. Other significant areas of improve-ment included acknowledgement that analgesia was morelikely to be consistently administered if a pain scoring sys-tem was utilised, that children age two years and under donot have reduced memory or sensitivity to pain and thatdoses of opioid can be titrated according to the individual’sresponse.

There were several positive albeit incidental findings of

this research which included 100% documentation of pre andpost analgesia pain score by ambulance officers exemplify-ing best practice. Compliance to weighing children at triagewas 100%. Weight is an essential measurement used for

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145

alculation of drugs when managing the paediatric patientnd children are mandatorily (where practical) weighedhen triaged in the department. Thus the incidental auditrovided evidence of consistent clinical practice.

ecommendations

everal target areas for improvement were identified in thistudy. These include the use of distraction, post analgesiaain assessment and documentation and time to analgesiarom triage. The identification of these barriers is valu-ble in providing impetus to change and improve practice.istraction was not well understood as an adjunctive toharmacological analgesia especially in the presence ofevere pain.

Formalised training in distraction techniques maymprove its use as an adjunct to pharmacological analge-ia. Delays in timely analgesia prompt a closer review of thenderlying practical processes, particularly at triage. Thisnding provides a baseline on which to develop strategiesuch as nurse initiated narcotic analgesia at triage and painanagement education. Whilst initial pain scores were wellocumented, ongoing pain assessment documentation wasxtremely poor. Further education and audit may promotehis practice. Practice may also be improved by the addi-ion of a pain score column to all clinical documentationheets. Currently this prompt is only provided on the initialmergency assessment documentation.

Continued adherence of the guideline will require ongo-ng support, education and audit. To achieve this goal theuideline has also been included in the nursing staff orien-ation manual and triage training and is located in posterorm at triage to support continuing education and use ofhe algorithm. Ongoing education and engagement of bothedical and nursing staff may address the barriers to timelyain management including attitudes to pain management,ack of knowledge and resources. Future data collectionocusing on audits of time to analgesia, pre and post painssessment documentation and adherence to the guide-ine in regard to prescription of analgesia, may provide aeedback mechanism which will potentially improve clinicalractice. Development of a parent/carer pain managementducational handout may further support pain managementy engaging the family in the process.

Systematic review of the literature revealed a paucity ofvidence regarding pain management of abdominal pain inhildren presenting to the emergency department. Futureirections may include continuing audit of time to analgesiarom triage to measure compliance to the guideline recom-endations. Compliance to specific medication in relation

o pain score was not assessed in this study, but could pro-ide insight into pain management practices in the future.ulti-centre trials utilising clinical guidelines may assist

n progressing and developing paediatric pain managementractices in the emergency department.

onclusion

his evidence based guideline has been trialled in the clini-al setting of paediatric emergency. The results of a postuideline implementation retrospective audit and survey

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ave demonstrated improved compliance to documentationf pain scores and assimilation of the guideline best prac-ice principles. This project raised local awareness of painanagement of abdominal pain and provides a baseline for

uture improvements. Introduction of the guideline at otherites has the potential to support consistent pain manag-ent practice and improve pain management for childrenresenting to the emergency department with abdominalain.

rovenance and conflict of interest

uthor Kerri Holzhauser is an Associate Editor of the Aus-ralasian Emergency Nursing Journal but had no role in theeer-review or editorial decision-making of the paper what-oever. No competing interests were declared for all otheruthors. This paper was not commissioned.

unding

his project was supported by a novice nursing and mid-ifery research grant from Queensland Health.

cknowledgements

he authors would like to acknowledge Dr Grant Stonend the staff of the Mater Children’s Hospital Emergencyepartment for their advice, support and contribution. The

iterature review would not have been possible withouthe expertise and enthusiasm of Kathy Hibberd, librarianrom the University of Queensland. Dr Geoff Spurling kindlyssisted with statistical design.

We would also like to thank the following members of thexpert panel for review and development of the guideline:r Rob Pitt, Staff Paediatrician, Nambour Hospital, Sharonluett, Nurse Educator Mater Children’s Hospital, Brisbane,elissa Prince, Clinical Nurse Consultant, Mater Children’sospital, Brisbane, Lorelle Maylon, Nurse Educator, Royalhildren’s Hospital, Brisbane, Scott Bennetts, Assistantirector, Effective Practice Program, National Institute oflinical Studies, National Health & Medical Research Coun-il, David M Pache, Senior Clinical Pharmacist Mater Healthervices, Conjoint Lecturer — School of Pharmacy, UQ.

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