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Are children in your ED suffering? Stop untreated pain now, guard accreditation
As an ED nurse, you work hard to stay current with clinical care for pediatrics. But are you effectively treating pain in infants and children? According to a just-published study, very young children with serious injuries often are undertreated for pain in the ED. The study compared pain medication use in children younger than 2 and school-age children, and it found that younger children often were not treated for pain, despite obviously painful conditions such as fractures and burn injuries.1 According to the Washington, DC-based National Safe Kids Campaign, 99,400 children ages 14 and younger were treated in EDs for burn-related injuries in 2001.
In addition, a 2002 survey of 123 EDs conducted by Maywood-based Illinois Emergency Medical Services for Children reported that only 50% of EDs offered analgesics to every pediatric patient who reported moderate to severe pain.2
These dramatic findings indicate that EDs could endanger their accreditation status with the Joint Commission on Accreditation of Healthcare Organizations, which is closely evaluating pain management in EDs, sources warn. Additionally, undertreatment of pain in pediatric patients can negatively affect your patient satisfaction scores, nurses say.
"When a parent presents with a child in pain, their anxiety is heightened, anyway," says Lynn Daum, RN, BSN, staff nurse in the ED at Cincinnati Children’s Hospital Medical Center, who adds that more than half of pediatric patients require some form of pain management. "If pain continues, that makes it worse."
If you control the child’s physical pain, you control the parents’ emotional pain, Daum points out. "If the parent feels the child is adequately cared for, patient satisfaction scores increase," she says.
You have another powerful incentive to improve pediatric pain management: A patient’s length of stay may increase if children’s pain is not managed, says Daum. "If the child is uncomfortable and crying, the parents may not be willing to go home," she explains.
To dramatically improve pain management of pediatric patients, make these changes:
• Develop a "pain-free" policy for children.
At Boston Medical Center, a PainFree Pediatrics Committee was formed to raise consciousness about pediatric pain and to identify practical, easy-to-use interventions, says Joan Meunier-Sham, RN, MS, the facility’s ED pediatric clinical nurse specialist.
The multidisciplinary committee includes nurses, physicians, pharmacists, and child-life specialists, says Meunier-Sham. A PainFree Pediatrics Protocol was developed to give nurses effective options when performing a painful procedure. (Chart listing for procedural pain management options for nurses.)
Before the protocol was initiated, ED nurses documented pain management interventions for children only 16% of the time, but they now are documented for 70% of patients, reports Meunier-Sham.
The ED at Children’s Medical Center in Dallas has a "Pain-Free Zone" program that stresses that pain is the fifth vital sign, says Linda L. Williams, BA, RN, CEN, education program manager.
According to the ED’s policy, nurses document vital signs every two hours, including pain assessment, says Williams. "Our charting form has a place for pain assessment that must be filled out every two hours," she adds.
• Give nurses several practical options for pain reduction.
"There are many quick methods of pain reduction that can be implemented in the ED," emphasizes Meunier-Sham.
Here are several options that work:
— Eulectic Mixture of Local Anesthetics (EMLA) Cream (AstraZeneca, Wilmington, DE). This emulsion of lidocaine and prilocaine is applied to intact skin, covered with an occlusive dressing, and can be used on infants older than 32 gestational weeks of age, says Meunier-Sham.
"EMLA must be left in place at least one hour, and it provides deeper anesthesia if left on up to three hours," she says.
Because of this time factor, EMLA cream is most commonly used in the ED for lumbar punctures and for children with chronic illnesses such as sickle cell disease, says Meunier-Sham.
— Numby Stuff. A battery-operated device delivers a solution of lidocaine with epinephrine through the skin’s surface and is used for children needing intravenous line (IV) placement, says Meunier-Sham. An electrode with medication is applied where the needlestick will be needed, and a second electrode is required to ground the current, she adds.
Application time varies from 10-20 minutes, and burning sensations and local irritation may occur, says Meunier-Sham. "Some patients experienced discomfort with the use of Numby Stuff, and therefore nurses tend to use it less," she adds.
Numby Stuff, manufactured by Salt Lake City, UT-based Iomed, is not used for infants or nonverbal children because you must be able to assess discomfort, she says. "If children cannot tell you that the Numby Stuff is uncomfortable or feels like it is burning, then it should not be used," says Meunier-Sham.
— ELA-Max. This is a lidocaine cream applied to the procedure site, and it is the newest product available for pediatric procedural pain, says Meunier-Sham. An occlusive dressing is not required, but it can decrease the risk of the child removing the bandage, she says.
The procedure site is numb within 20 minutes, and anesthesia will increase for up to two hours, says Meunier-Sham.
ELA-Max is favored over EMLA cream because ELA-Max has rapid onset of action, she reports. However, ELA-Max (Ferndale Laboratories, Ferndale, MI) does not have approval from the Food and Drug Administration for use in children younger than 1 year of age, she notes.
— Vapocoolants. These refrigerants are sprayed on the skin surface and provide an immediate cooling that only lasts for 5-10 seconds. They are used for venipuncture and IV line placements in the ED, says Meunier-Sham. "Therefore, following application, the area should be cleansed with an alcohol swab, immediately followed by the needlestick," she says.
Vapocoolants are very cold, and if applied for too long, they can cause frostbite, she warns. "Vapocoolants should not be used in anyone with peripheral vascular disease," says Meunier-Sham.
— Sucrose pacifiers. Administering these to infants up to three months of age decreases grimacing, crying, and tachycardia during painful procedures, says Meunier-Sham.
Up to 2 cc of solution is slowly administered to the infant, with smaller volumes used for premature infants, says Meunier-Sham. "During the procedure, the infant may suck on a gloved finger or pacifier dipped in the remaining solution," she says.
At Children’s, the ED recently began using oral sucrose for neonate pain control before invasive procedures, says Williams. "This has allowed us to perform needle punctures and placement of urinary catheters without a cry from many young babies," she says.
— Lidocaine, epinephrine, and tetracaine cream.
Before lacerations are cleaned, ED nurses apply this topical gel, says Williams. "This product has substantially reduced the pain of irrigation and cleaning of these wounds," she says.
• Designate a pain resource nurse.
The goal is to ensure that every child receives timely, appropriate management of his or her pain, says Lori Vinson, RN, pain resource nurse for the ED at Children’s Medical Center of Dallas.
All ED nurses complete a pain management competency on an annual basis, says Vinson, who gives ongoing education on pain management topics such as sucrose pacifiers.
"I serve as a resource to the nurses when they have questions about pain management," she says. "I am also an advocate with the nurse by working with the physician and the pharmacist for a plan of care that includes pain management."
• Have ED nurses start interventions directly.
Although ED nurses often initiate painful procedures, a physician order was needed for pharmacologic agents, says Meunier-Sham. To address this, a "nurse-driven protocol" was developed, with a preprinted order for "PainFree Protocol Measures" allowing nurses to choose and initiate procedural pain management, she explains.
"This empowers ED nurses to use pharmacological and non-pharmacological interventions to decrease procedural pain," she says. "Nurses have the autonomy to choose the appropriate option for use, as long as they follow the protocol."
From the moment the child is triaged, pain is assessed and pain control measures are put in place, says Williams. For example, triage nurses may splint, elevate, and apply ice to a fractured extremity, or may administer acetaminophen or ibuprofen, she says.
"Topical EMLA is applied to potential IV sites or to the lower back if a lumbar puncture is anticipated at triage, or applied immediately when the child is placed in a treatment room," says Williams.
1. Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med 2003; 41:617-622.
2. Illinois Emergency Medical Services for Children. Pediatric Pain Management Survey and Quality Improvement Monitor. 2002. Web: www.ems-c.org/Products/frameproducts.htm.
For more information about pain management in pediatric patients, contact:
• Lynn Daum, RN, BSN, Emergency Services, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039. Telephone: (513) 636-1831. E-mail: Lynn.Daum@cchmc.org.
• Joan Meunier-Sham, RN, MS, Pediatric Clinical Nurse Specialist, Emergency Department, Boston Medical Center, One Medical Center Place, Boston, MA 02118. Telephone: (617) 414-4208. Fax: (617) 414-4999. E-mail: Joan.Sham@bmc.org.
• Lori Vinson, RN, Pain Resource Nurse, Emergency Center, Children’s Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-2291. E-mail: firstname.lastname@example.org.
• Linda L. Williams, BA, RN, CEN, Education Program Manager, Emergency Center, Children’s Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-8538. E-mail: Liwill@childmed.dallas.tx.us.