Pediatric Pain Assessment in the Emergency Department
Pediatric Pain Assessment in the Emergency Department
This project provided a mechanism to deliver evidence-based pediatric pain assessment and management education to all ED nursing staff. This project also included the implementation of a pediatric pain assessment protocol and measurement of nurses' medical record documentation to evaluate adherence to identified practices.
This education program offering was carefully planned to support staff's completion of the program. Unfortunately, the hospital's human resources department was not identified as a key stakeholder related to the timing of the education program. A number of hospital-wide human resources electronic learning assignments occurred concurrently with this education program. The abundance of assignments at the same time may have contributed to the overall program completion of only 75%.
Lower-than-expected pre-test scores may be a result of variability of pediatric pain content across schools of nursing and participation in routine pediatric pain-related continuing education. Although a significant in - crease in post-test scores is evident, these scores were also lower than expected given the participant-reported outstanding achievement of program objectives and confidence in assessing pediatric pain after program completion.
The high percentage of patients assessed for pain using an appropriate scale demonstrates nurses' understanding of the unique developmental and cognitive implications for pediatric pain assessment. This was especially impressive as the protocol included the addition of the two new pain assessment scales. Although nurses in this ED demonstrated increased knowledge, overall comfort in pediatric pain assessment, and a favorable desire to incorporate new pain knowledge from this program into practice, the EMR review highlighted variability in actual adherence to practice, including 1) adherence to use of correct pain scale, 2) adherence to pain assessment at triage, 3) non-adherence to documentation of pain location and additional pain characteristics, and 4) non-adherence to pain assessment post-intervention and prior to discharge from the ED.
Although many patients had pain, defined as pain score greater than or equal to one, few received an intervention for pain. This project did not include recommendations for the selection of pharmacologic or non-pharmacologic intervention based on the severity of pain. As a result of this project limitation, it is possible some patients did not receive intervention due to low pain severity or lack of pharmacologic orders. It is also possible that nurses did use, but did not document, non-pharmacologic interventions. Further exploration is needed to evaluate nursing and physician specific pain management practices in this department. Nurses' low adherence to post-intervention and pre-discharge protocol assessments needs further exploration. The addition of missing documentation alerts in the EMR may be useful to remind nurses of the need to document reassessment of pain following pain intervention. The inclusion of pain assessment in routine pre-discharge vital signs may also increase nurses' adherence.
Of interest, the highest percentage of pain location documentation occurred in triage. It may be assumed that pain location remains constant, unless otherwise indicated, for the remainder of the visit thus subsequent documentation of pain location was lacking. Few patients had documentation of additional pain characteristics. Although these practices were recommended by EMSC, further assessment is needed to determine barriers to use in this ED.
Discussion and Nursing Implications
This project provided a mechanism to deliver evidence-based pediatric pain assessment and management education to all ED nursing staff. This project also included the implementation of a pediatric pain assessment protocol and measurement of nurses' medical record documentation to evaluate adherence to identified practices.
This education program offering was carefully planned to support staff's completion of the program. Unfortunately, the hospital's human resources department was not identified as a key stakeholder related to the timing of the education program. A number of hospital-wide human resources electronic learning assignments occurred concurrently with this education program. The abundance of assignments at the same time may have contributed to the overall program completion of only 75%.
Lower-than-expected pre-test scores may be a result of variability of pediatric pain content across schools of nursing and participation in routine pediatric pain-related continuing education. Although a significant in - crease in post-test scores is evident, these scores were also lower than expected given the participant-reported outstanding achievement of program objectives and confidence in assessing pediatric pain after program completion.
The high percentage of patients assessed for pain using an appropriate scale demonstrates nurses' understanding of the unique developmental and cognitive implications for pediatric pain assessment. This was especially impressive as the protocol included the addition of the two new pain assessment scales. Although nurses in this ED demonstrated increased knowledge, overall comfort in pediatric pain assessment, and a favorable desire to incorporate new pain knowledge from this program into practice, the EMR review highlighted variability in actual adherence to practice, including 1) adherence to use of correct pain scale, 2) adherence to pain assessment at triage, 3) non-adherence to documentation of pain location and additional pain characteristics, and 4) non-adherence to pain assessment post-intervention and prior to discharge from the ED.
Although many patients had pain, defined as pain score greater than or equal to one, few received an intervention for pain. This project did not include recommendations for the selection of pharmacologic or non-pharmacologic intervention based on the severity of pain. As a result of this project limitation, it is possible some patients did not receive intervention due to low pain severity or lack of pharmacologic orders. It is also possible that nurses did use, but did not document, non-pharmacologic interventions. Further exploration is needed to evaluate nursing and physician specific pain management practices in this department. Nurses' low adherence to post-intervention and pre-discharge protocol assessments needs further exploration. The addition of missing documentation alerts in the EMR may be useful to remind nurses of the need to document reassessment of pain following pain intervention. The inclusion of pain assessment in routine pre-discharge vital signs may also increase nurses' adherence.
Of interest, the highest percentage of pain location documentation occurred in triage. It may be assumed that pain location remains constant, unless otherwise indicated, for the remainder of the visit thus subsequent documentation of pain location was lacking. Few patients had documentation of additional pain characteristics. Although these practices were recommended by EMSC, further assessment is needed to determine barriers to use in this ED.
