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Is Fever Treated More Promptly Than Pain in the Pediatric Emergency Department?
The Journal of Emergency Medicine, Vol. 46, No. 3, pp. 327–334, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.08.063
Original Contributions
IS FEVER TREATED MORE PROMPTLY THAN PAIN IN THE PEDIATRIC EMERGENCY DEPARTMENT? Ronald Dvorkin, MD,* Jacob Bair, DO,* Hardik Patel, MBBS,* Sanford Glantz, MD,* David P. Yens, PHD,† Anthony Rosalia Jr., MD,* and Jeffrey Marguilies, MD* *Good Samaritan Hospital Medical Center, West Islip, New York and †New York Colleges of Osteopathic Medicine Educational Consortium, Old Westbury, New York Reprint Address: Ronald Dvorkin, MD, Good Samaritan Hospital Medical Center, 1000 Montauk Highway, West Islip, NY 11795
, Abstract—Background: Fever can be treated with a higher priority than pain in the pediatric emergency department (ED) population. Objective: The primary objective was to assess whether patients with a fever are treated with acetaminophen or ibuprofen more promptly than they are treated for pain. Methods: A retrospective descriptive study was performed on all patients between the ages of 3 and 19 years who received acetaminophen or ibuprofen in the pediatric ED from February 1, 2010 to January 31, 2011. The time interval from arrival to treatment with acetaminophen or ibuprofen was compared for those patients with a fever ($100.4 F) and those without a fever and had reported pain. Other measurable points (time of vital signs, bed assignment, and medication order) on the medical record were compared to further describe any differences. Results: Pediatric patients with fever (n = 1097) received ibuprofen or acetaminophen a median of 54.0 min (interquartile range [IQR], 35.4 89.3 min) after arrival. The corresponding median time for afebrile patients (n = 1861) that received the same medications was 83.2 min (IQR, 52.7 136.1). The difference between medians was 24.6 min (95% confidence interval 21.3 27.9 min). Conclusions: Fever is treated more promptly than pain in the pediatric ED. This difference is associated with prevailing and largely unfounded concerns about fever and the undertreatment of pain (oligoanalgesia). Ó 2014 Elsevier Inc.
INTRODUCTION Pain is often not treated promptly or adequately in the emergency department (ED) (1). Lack of adequate pain management has been referred to as oligoanalgesia. Withholding of analgesics of any type does not obscure evaluation of patient and clinical diagnosis (2). We were specifically interested in the time of delivery of the noncontrolled analgesics, acetaminophen and ibuprofen, to pediatric patients. There is no evidence to indicate that lowering a child’s moderate temperature elevation improves clinical outcome, and there is evidence that prompt treatment of pain may be beneficial (3 6). In a January 2010 pilot study, data obtained from routine chart reviews demonstrated that patients with fever obtained acetaminophen or ibuprofen more promptly than patients with pain. We wished to compare any time differences to the delivery of the same antipyretic and analgesic medications between febrile and afebrile patients. The primary objective was to compare the time from patient arrival to the administration of acetaminophen or ibuprofen for patients with a temperature $100.4 F with those patients with a temperature <100.4 F. Other measurable points (time of vital signs, bed assignment, and medication order) on the medical record were also examined to further describe any differences. A separate analysis to
, Keywords—acetaminophen; acuity; database; electronic medical record; emergency department; fever; ibuprofen; pain; pediatric; triage
RECEIVED: 9 January 2013; FINAL SUBMISSION RECEIVED: 13 July 2013; ACCEPTED: 15 August 2013 327
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determine the individual effects of temperature, pain, age, and acuity on the time to treatment was also performed. METHODS Study Design and Setting
Data extracted included hospital account number; age; sex; acuity; ethnic group; primary diagnosis; arrival date/time; triage date/time; vital signs date/time and pain scale; bed assignment date/time; medication and order date/time; and medication administration date/time. Outcome Measures
A retrospective descriptive study was done in a suburban academic ED with an annual census of 100,000 patients. Approximately 30,000 visits are seen in a dedicated pediatric ED. The hospital’s Institutional Review Board approved the protocol. From the 30,000 pediatric ED visits (February 1, 2010 to January 31, 2011), all patients that received acetaminophen or ibuprofen in the pediatric ED (n = 5322) were analyzed. Of these 15 patients were excluded because of missing or incomplete data. There were 3244 patients that were between the ages of 3 and 19 years who received either medication. An additional 286 patients were excluded who were afebrile with a pain score of 0, leaving 2958 patients that were analyzed (Figures 1 and 2). Data were abstracted from the electronic medical record (Allscripts EDÔ, formerly Healthmatics A4Ô) for patients that received acetaminophen or ibuprofen. This computerized patient charting and order-entry system enabled the collection of standardized information for each patient and integrated that information into a relational database. The database was queried by SQL Cognos ImpromptuÔ (Cognos) IBM (Armonk, NY), which allows the administrator to create reports using criteria filters. This has been described elsewhere (7,8). Using the inclusion criteria listed here, a report was created with Cognos that queried all patients seen in the ED that fit the criteria for study enrollment. This report was further analyzed by Excel 2007 (Microsoft, Redmond, WA), using tools that Cognos does not possess, on patients between the ages of 3 and 19 years that were medicated with acetaminophen or ibuprofen (Figures 1 and 2). Patients given acetaminophen or ibuprofen were included if all data were available from time of arrival, including time of vital signs; time of bed assignment; time of medication order, and time medication was administered; the patient was seen in the pediatric ED (not in the Fast Track or other treatment areas); the patient did not have a temperature >106 F; and if the patient was afebrile had an initial report of pain $1. All medications were ordered by physicians or nurse practitioners. The ED had no standing orders for the administration of medications by nurses.
Figure 1. Patient management time intervals (n = 2958).
The primary outcome measured was the arrival time to the time of medication. Also measured were the intervals from vital signs to medication administration, medication order to medication administration, and bed assignment to medication administration. Demographics and pain scales utilizing an 11-point scale (0 10) were also assessed. Data Analysis Data were analyzed using StatsDirect (Cheshire, UK) for nonparametric data and IBM SPSS Version 21 for parametric analyses. RESULTS Patient demographics are listed in Table 1. During the 1-year study period, all patients who received acetaminophen or ibuprofen in the pediatric ED and met study criteria were included. There were 1097 patients who presented with a temperature $100.4 F and 1861 patients who presented with a temperature <100.4 F and were reported to be in pain. The data demonstrated that it took longer to administer medication to afebrile children. The difference in medians from the time of arrival to medication administration was 24.6 min (95% confidence interval [CI] 21.3 27.9 min). All other components of this time interval were also significantly different (p < 0.01) (Table 2 and Figure 3). Median pain score for afebrile children was significantly higher as compared with the febrile children, with a pain score of 6 (interquartile range [IQR], 5 8) for afebrile children vs. 3 (IQR, 0 6) for febrile children (median difference = 2; 95% CI 2 3; p < 0.01). A five-tiered triage category was used, with the lowest number having the greatest acuity (9). The median tier was 3 for both the febrile and afebrile groups. Patient demographics except for age and race were similar (Table 1). Fewer febrile patients tended to be white, as compared with afebrile patients (44.3% vs. 53.7%). When times to medication administration by age (Table 3) and acuity (Table 4) were stratified, patients with fever were always treated more promptly than those that were afebrile. Young febrile children were treated more quickly than older febrile children. A separate secondary analysis was used to determine the individual effects of temperature, pain, age, and
Treatment of Fever and Pain
329
Figure 2. Flow of patient visits that were analyzed during the 1-year study period. ED = emergency department.
acuity on the time to treatment. The central 80% of data by time to treatment was found to be approximately normally distributed. A multiple linear regression analysis on the central 80% of these data was performed. The regression analysis of variance with time to treatment as dependent was statistically significant (F2361 = 31.45; p < 0.001) using all predictors. Three of four coefficients were significant: temperature elevation, acuity, and age (all, p < 0.01). Pain scale was not a significant predictor for time to treatment. To provide relatively unbiased determination of correlations, the partial correlation between variables was determined. The partial correlation is the correlation between variables ignoring the contribution of other variables. The partial correlation of time to drug administration with the temperature elevation was statistically significant (rpartial = 0.105; p < 0.01), but the partial correlation of time to drug administration using the pain scale was not statistically significant (rpartial = 0.03; p = NS). Age was also correlated with time to treatment (rpartial = 0.101; p < 0.01) as well as acuity (rpartial = 0.07; p < 0.01). This analysis is consistent with the finding that time to drug administration was more strongly correlated with fever, age, and acuity than with pain.
DISCUSSION It has been shown that fever phobia contributes to undue concerns about elevated temperature and others have shown that oligoanalgesia is a significant problem (1,6,10 14). The study looked at the effect of these well-described concerns on the time to treatment and found a large and significant difference between the two groups. The combination of undue concern for temperature elevation and insufficient concern for the treatment of pain possibly had a cumulative effect and may have contributed to the large time disparity between the two groups. Oligoanalgesia can have adverse consequences for patients of all ages. Although outside the scope of this study, infants circumcised without anesthesia exhibited stronger pain responses to subsequent routine immunizations during the first 6 months of life than infants who were not circumcised, suggesting that pain might exert long-term effects on infant behavior. Inadequate treatment of pain in children has been noted to increase pain ratings during subsequent procedures (13,14). In a study that evaluated out-of-hospital administration of analgesics, one third of parents who did not administer analgesics to their
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Table 1. Patient Demographics
Characteristic Age (years) (SD) Sex (% female) Race (% white)
Temperature <100.4 F Temperature $100.4 F (n = 1861) (n = 1097) 11.9 (4.8) 52.1 53.7
6.9 (4.1) 53.2 44.3
SD = standard deviation.
children thought that giving analgesics would be harmful (15). Adolescents have been described as most vulnerable to experiencing unrelieved pain (5). It has also been noted that when pain is not promptly treated in young adults, there is a higher incidence of post-traumatic stress disorder (6). Fever is the single most common nontrauma-related reason for a visit to the pediatric ED (16). There is no information in the literature to suggest that treating a fever in pediatric patients has any beneficial effect on morbidity. However, there are parental concerns about the need to treat fever promptly (11,12,17). There is also misguided concern that untreated fever can cause seizures (18 20). Physicians themselves have recommended prompt treatment of fever, despite there being some evidence to the contrary (21). Fever can enhance body defense mechanisms during infection (4). Some bacteria have growth inhibition at higher temperatures. Human lymphocytes have increased metabolic activity and leukocytes exhibit increased phagocytic activity at moderate temperature elevations (3). It has been suggested if children are tolerating their fevers well, without irritability, lethargy, or delirium, perhaps care providers should not remove a potential host defense mechanism by giving antipyretics (4). Although there are various mechanisms to determine pain for infants and children, the study was designed to
analyze those 3 to 19 years of age because of their ability to better verbalize their pain. If patients younger than 3 years of age were included, the disparity would have been greater by approximately 7 min. Although there are validated methods of measuring pain in the 0 to 3-year age range, the study was designed specifically to address concerns that these methods might not be universally used in one area that triages both pediatric and adult patients (22,23). Part of time-to-treatment discrepancies between fever and pain might be the tendency to best treat what can be quantified. Temperature is objectively measured and reliably lowered by treatment, bringing a sense of accomplishment to the caregiver, even though objective improvement of the temperature might not correlate well with patient outcomes. Pain scales, on the other hand, are harder to measure and changes are harder to objectively assess (24). Pain in children has sometimes been trivialized in older literature that suggests that children to not remember pain. Pain might be undertreated due to inexact measurement and outmoded notions that prompt treatment is not important (25). In this study, fewer febrile patients tended to be white as compared with afebrile patients. Perhaps younger children tended to be non-white as compared with older children with elevated temperatures, as fever phobia seems to vary by ethnicity (26 28). There was an assumption that the primary purpose for administering these drugs in the febrile child was for the treatment of fever, although pain could have been present also. There was a significant difference in the median pain score reported in the febrile vs. afebrile group. The findings demonstrate that priorities for treating pediatric emergency patients with acetaminophen and ibuprofen are seemingly reversed. The reasons for this disparity are not answered by the data. In all the time intervals we measured, there was a significant difference
Table 2. Time Component Intervals to Medication Administration Median Time to Medication Administration (min) (IQR)
Median Interval (min) Interval
Temperature <100.4 F (n = 1861)
Temperature $100.4 F (n = 1097)
Difference Between Medians*
Arrival to medication administration Bed assignment to medication administration Vital signs to medication administration Medication order to medication administration
83.2 80.2 76.3 8.0
54.0 51.5 46.5 7.1
24.6 24.9 24.6 0.9
95% CI* 21.3 21.6 21.4 0.4
27.9 28.3 27.9 1.3
IQR = interquartile range. Median times to medication administration from patient arrival, bed assignment, vital signs obtained, and medication ordered for the administration of either acetaminophen or ibuprofen are given. Median time to medication administration for febrile patients was shorter for each group (p < 0.01 for all groups). * As determined by the Mann-Whitney U test StatsDirect (Cheshire, UK).
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Figure 3. The median time intervals for afebrile vs. febrile patients for medication administration from arrival (83.2 vs. 54.0 min), bed assignment (80.1 vs. 51.5 min), vital sign documentation (76.3 vs. 45.6 min), and medication order (8.0 vs. 7.1 min), along with interquartile intervals (IQ). IQ3 = 3rd quartile; IQ1 = 1st quartile.
with febrile children getting medication sooner. When differences for each age group and for each acuity classification were analyzed by both stratification and by examining partial correlations, the disparities were found to be similar, thus arguing against bias by confounding variables. There have been ED practices that make pain management a high priority by establishing treatment guidelines; measuring practice outcomes and education does produce changes in the attitudes and practices of care providers and improve patient satisfaction (29,30). There might be a continued misperception by children’s caregivers that prioritizes antipyresis over analgesia.
Although we do not advocate withholding antipyretics, we do advocate timely management of pain. Limitations This was a retrospective study and can only demonstrate an association rather than a causal relationship. This study was performed at only one hospital, which limits the ability to generalize the results to other settings. The study did not specifically determine what influenced the health care provider to prescribe a medication, nor was the diagnosis ascertained for each patient. Certainly, some of the febrile patients did report some
Table 3. Stratification by Age No. of Patients in Each Age Group
Median Time to Medication Administration (min)
Age (years)
Temperature <100.4 F
Temperature $100.4 F
Temperature <100.4 F
Temperature $100.4 F
$3 to <6 $6 to <9 $9 to <12 $12 to <15 $15 to <19 $3 to <19
311 277 273 346 654 1861
647 202 99 61 88 1097
77.4 81.2 74.7 82.8 94.9 83.2
51.5 54.9 55.1 56.1 66.1 54.0
Median times from patient arrival to the administration of either acetaminophen or ibuprofen are given for each age group along with the number of patients in each age group. Median time to medication administration for febrile patients was shorter for all age groups (p < 0.01).
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Table 4. Stratification by Acuity Number of Patients in Each Acuity Group Acuity 2 3 4 5 All
Temperature <100.4 F
Temperature $100.4 F
244 1329 283 5 1861
142 940 14 1 1097
Median Time to Medication Administration in Minutes (IQR) Temperature <100.4 F 87.1 (54.5 88.0 (56.0 64.5 (43.3 50.2 (42.0 83.2 (52.7
151.3) 141.9) 102.0) 59.0) 136.1)
Temperature $100.4 F 45.5 (31.3 55.2 (36.3 53.5 (42.9 28.9 (28.9) 54.0 (35.4
83.7) 89.8) 73.9) 89.3)
IQR = interquartile range. Median times from patient arrival to administration of either acetaminophen or ibuprofen are given for each acuity group along with the number of patients in each acuity group. Median time to medication administration for febrile patients was shorter for acuity groups 2 to 5.
pain. Some patients had both pain and fever and were included in the fever category. Eliminating these patients did not appreciably alter the results. Other factors might be related to the timing and decision to administer acetaminophen or ibuprofen, such as abnormal vital signs, ED prioritization system, time of presentation, etc. The study was not designed to analyze these factors. Patients who received opioids for their pain were not included and therefore patients with the most severe pain may have been excluded. Opioids administered were almost always oral codeine or i.v. morphine. There were relatively few instances of oral opioids (as most extremity fractures and lacerations were treated in the Fast Track area and not in the pediatric ED). Intravenous opioids were given only after i.v. access was obtained and the time to i.v. access was most often >60 min. Including patients that received opioids would not have affected the overall results. The study did not provide any data on the type of pain or response to treatment. It was not designed to determine whether pain was adequately treated and if the patient might have required a controlled substance for analgesia. The level of oligoanalgesia was not elucidated. It is theoretically possible that adequate pain control was already provided to the ED patients. However, we were unable to find any mention in the literature of instances where there was overtreatment or overmedication for pain in the ED, and we have no reason to believe that the practice pattern in our ED differs in this regard. The results could be influenced by variations in individual provider practice, and the study did not control for the effect of clustering by individual providers. Providers see patients on a next-patient basis and do not choose the next patient to be seen, thus minimizing this type of selection bias. CONCLUSIONS Pediatric patients are treated sooner with acetaminophen or ibuprofen when presenting with fever than those who
do not have a fever but do have pain. We believe this difference is associated with continuing and prevailing unnecessary concerns about fever and the prevalence of oligoanalgesia, the undertreatment of pain.
REFERENCES 1. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med 1989;7:620–3. 2. Silen W. Early diagnosis of the acute abdomen. 21 edn. New York: Oxford University Press; 2005. 3. Zanker KS, Lange J. Whole body hyperthermia and natural killer cell activity. Lancet 1982;1(8280):1079–80. 4. Zitelli BJ. Fever phobia and the adaptive value of fever. Indian J Pediatr 1991;58:275–8. 5. Crandall M, Miaskowski C, Kools S, Savedra M. The pain experience of adolescents after acute blunt traumatic injury. Pain Manag Nurs 2002;3:104–14. 6. Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dougherty AL. Morphine use after combat injury in Iraq and post-traumatic stress disorder. N Engl J Med 2010;362:110–7. 7. McGerald G, Dvorkin R, Levy D, Lovell-Rose S, Sharma A. Prescriptions for schedule II opioids and benzodiazepines increase after the introduction of computer-generated prescriptions. Acad Emerg Med 2009;16:508–12. 8. Sharma AN, Dvorkin R, Tucker V, Margulies J, Yens D, Rosalia A Jr. Medical reconciliation in patients discharged from the emergency department. J Emerg Med 2012;43:366–73. 9. Eitel DR, Travers DA, Rosenau AM, Gilboy N, Wuerz RC. The emergency severity index triage algorithm version 2 is reliable and valid. Acad Emerg Med 2003;10:1070–80. 10. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years? Pediatrics 2001;107:1241–6. 11. Nelson DS. Emergency treatment of fever phobia. J Emerg Nurs 1998;24:83–4. 12. Purssell E. Parental fever phobia and its evolutionary correlates. J Clin Nurs 2009;18:210–8. 13. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349(9052):599–603. 14. Weisman SJ, Bernstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med 1998;152:147–9. 15. Spedding RL, Harley D, Dunn FJ, McKinney LA. Who gives pain relief to children? J Accid Emerg Med 1999;16:261–4. 16. Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of pediatric illness presenting to a general community hospital emergency department. Pediatrics 1992;90(1 Pt 1):5–10. 17. Kramer MS, Naimark L, Leduc DG. Parental fever phobia and its correlates. Pediatrics 1985;75:1110–3.
Treatment of Fever and Pain 18. Camfield PR, Camfield CS, Shapiro SH, Cummings C. The first febrile seizure—antipyretic instruction plus either phenobarbital or placebo to prevent recurrence. J Pediatr 1980;97:16–21. 19. Schnaiderman D, Lahat E, Sheefer T, Aladjem M. Antipyretic effectiveness of acetaminophen in febrile seizures: ongoing prophylaxis versus sporadic usage. Eur J Pediatr 1993;152:747–9. 20. Uhari M, Rantala H, Vainionpaa L, Kurttila R. Effect of acetaminophen and of low intermittent doses of diazepam on prevention of recurrences of febrile seizures. J Pediatr 1995;126:991–5. 21. May A, Bauchner H. Fever phobia: the pediatrician’s contribution. Pediatrics 1992;90:851–4. 22. Joyce BA, Schade JG, Keck JF, et al. Reliability and validity of preverbal pain assessment tools. Issues Compr Pediatr Nurs 1994;17:121–35. 23. van Dijk M, de Boer JB, Koot HM, Tibboel D, Passchier J, Duivenvoorden HJ. The reliability and validity of the COMFORT scale as a postoperative pain instrument in 0 to 3-year-old infants. Pain 2000;84:367–77. 24. Probst BD, Lyons E, Leonard D, Esposito TJ. Factors affecting emergency department assessment and management of pain in children. Pediatr Emerg Care 2005;21:298–305.
333 25. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001; 108:793–7. 26. Cohee LM, Crocetti MT, Serwint JR, Sabath B, Kapoor S. Ethnic differences in parental perceptions and management of childhood fever. Clin Pediatr (Phila) 2010;49:221–7. 27. Nijman RG, Oostenbrink R, Dons EM, Bouwhuis CB, Moll HA. Parental fever attitude and management: influence of parental ethnicity and child’s age. Pediatr Emerg Care 2010;26:339–42. 28. Rupe A, Ahlers-Schmidt CR, Wittler R. A comparison of perceptions of fever and fever phobia by ethnicity. Clin Pediatr (Phila) 2010;49:172–6. 29. Chan L, Russell TJ, Robak N. Parental perception of the adequacy of pain control in their child after discharge from the emergency department. Pediatr Emerg Care 1998;14:251–3. 30. Kelly AM. A process approach to improving pain management in the emergency department: development and evaluation. J Accid Emerg Med 2000;17:185–7.
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ARTICLE SUMMARY 1. Why is this topic important? Undertreatment of pain is a persistent problem with the potential for adverse effects. Fever may be treated with a higher priority than pain in the pediatric emergency department population. 2. What does this study attempt to show? Our primary objective was to assess whether patients with a fever are treated more promptly with acetaminophen or ibuprofen than those without a fever. 3. What are the key findings? Our study found that patients with fever are treated more promptly than those with pain. 4. How is patient care impacted? There appears to be an inherent tendency to treat fever sooner than pain. The combination of undue concern for temperature elevation and insufficient concern for the treatment of pain may have a cumulative effect and may have contributed to a time disparity between the two groups.
http://dx.doi.org/10.1016/j.jemermed.2013.08.063
Original Contributions
IS FEVER TREATED MORE PROMPTLY THAN PAIN IN THE PEDIATRIC EMERGENCY DEPARTMENT? Ronald Dvorkin, MD,* Jacob Bair, DO,* Hardik Patel, MBBS,* Sanford Glantz, MD,* David P. Yens, PHD,† Anthony Rosalia Jr., MD,* and Jeffrey Marguilies, MD* *Good Samaritan Hospital Medical Center, West Islip, New York and †New York Colleges of Osteopathic Medicine Educational Consortium, Old Westbury, New York Reprint Address: Ronald Dvorkin, MD, Good Samaritan Hospital Medical Center, 1000 Montauk Highway, West Islip, NY 11795
, Abstract—Background: Fever can be treated with a higher priority than pain in the pediatric emergency department (ED) population. Objective: The primary objective was to assess whether patients with a fever are treated with acetaminophen or ibuprofen more promptly than they are treated for pain. Methods: A retrospective descriptive study was performed on all patients between the ages of 3 and 19 years who received acetaminophen or ibuprofen in the pediatric ED from February 1, 2010 to January 31, 2011. The time interval from arrival to treatment with acetaminophen or ibuprofen was compared for those patients with a fever ($100.4 F) and those without a fever and had reported pain. Other measurable points (time of vital signs, bed assignment, and medication order) on the medical record were compared to further describe any differences. Results: Pediatric patients with fever (n = 1097) received ibuprofen or acetaminophen a median of 54.0 min (interquartile range [IQR], 35.4 89.3 min) after arrival. The corresponding median time for afebrile patients (n = 1861) that received the same medications was 83.2 min (IQR, 52.7 136.1). The difference between medians was 24.6 min (95% confidence interval 21.3 27.9 min). Conclusions: Fever is treated more promptly than pain in the pediatric ED. This difference is associated with prevailing and largely unfounded concerns about fever and the undertreatment of pain (oligoanalgesia). Ó 2014 Elsevier Inc.
INTRODUCTION Pain is often not treated promptly or adequately in the emergency department (ED) (1). Lack of adequate pain management has been referred to as oligoanalgesia. Withholding of analgesics of any type does not obscure evaluation of patient and clinical diagnosis (2). We were specifically interested in the time of delivery of the noncontrolled analgesics, acetaminophen and ibuprofen, to pediatric patients. There is no evidence to indicate that lowering a child’s moderate temperature elevation improves clinical outcome, and there is evidence that prompt treatment of pain may be beneficial (3 6). In a January 2010 pilot study, data obtained from routine chart reviews demonstrated that patients with fever obtained acetaminophen or ibuprofen more promptly than patients with pain. We wished to compare any time differences to the delivery of the same antipyretic and analgesic medications between febrile and afebrile patients. The primary objective was to compare the time from patient arrival to the administration of acetaminophen or ibuprofen for patients with a temperature $100.4 F with those patients with a temperature <100.4 F. Other measurable points (time of vital signs, bed assignment, and medication order) on the medical record were also examined to further describe any differences. A separate analysis to
, Keywords—acetaminophen; acuity; database; electronic medical record; emergency department; fever; ibuprofen; pain; pediatric; triage
RECEIVED: 9 January 2013; FINAL SUBMISSION RECEIVED: 13 July 2013; ACCEPTED: 15 August 2013 327
328
R. Dvorkin et al.
determine the individual effects of temperature, pain, age, and acuity on the time to treatment was also performed. METHODS Study Design and Setting
Data extracted included hospital account number; age; sex; acuity; ethnic group; primary diagnosis; arrival date/time; triage date/time; vital signs date/time and pain scale; bed assignment date/time; medication and order date/time; and medication administration date/time. Outcome Measures
A retrospective descriptive study was done in a suburban academic ED with an annual census of 100,000 patients. Approximately 30,000 visits are seen in a dedicated pediatric ED. The hospital’s Institutional Review Board approved the protocol. From the 30,000 pediatric ED visits (February 1, 2010 to January 31, 2011), all patients that received acetaminophen or ibuprofen in the pediatric ED (n = 5322) were analyzed. Of these 15 patients were excluded because of missing or incomplete data. There were 3244 patients that were between the ages of 3 and 19 years who received either medication. An additional 286 patients were excluded who were afebrile with a pain score of 0, leaving 2958 patients that were analyzed (Figures 1 and 2). Data were abstracted from the electronic medical record (Allscripts EDÔ, formerly Healthmatics A4Ô) for patients that received acetaminophen or ibuprofen. This computerized patient charting and order-entry system enabled the collection of standardized information for each patient and integrated that information into a relational database. The database was queried by SQL Cognos ImpromptuÔ (Cognos) IBM (Armonk, NY), which allows the administrator to create reports using criteria filters. This has been described elsewhere (7,8). Using the inclusion criteria listed here, a report was created with Cognos that queried all patients seen in the ED that fit the criteria for study enrollment. This report was further analyzed by Excel 2007 (Microsoft, Redmond, WA), using tools that Cognos does not possess, on patients between the ages of 3 and 19 years that were medicated with acetaminophen or ibuprofen (Figures 1 and 2). Patients given acetaminophen or ibuprofen were included if all data were available from time of arrival, including time of vital signs; time of bed assignment; time of medication order, and time medication was administered; the patient was seen in the pediatric ED (not in the Fast Track or other treatment areas); the patient did not have a temperature >106 F; and if the patient was afebrile had an initial report of pain $1. All medications were ordered by physicians or nurse practitioners. The ED had no standing orders for the administration of medications by nurses.
Figure 1. Patient management time intervals (n = 2958).
The primary outcome measured was the arrival time to the time of medication. Also measured were the intervals from vital signs to medication administration, medication order to medication administration, and bed assignment to medication administration. Demographics and pain scales utilizing an 11-point scale (0 10) were also assessed. Data Analysis Data were analyzed using StatsDirect (Cheshire, UK) for nonparametric data and IBM SPSS Version 21 for parametric analyses. RESULTS Patient demographics are listed in Table 1. During the 1-year study period, all patients who received acetaminophen or ibuprofen in the pediatric ED and met study criteria were included. There were 1097 patients who presented with a temperature $100.4 F and 1861 patients who presented with a temperature <100.4 F and were reported to be in pain. The data demonstrated that it took longer to administer medication to afebrile children. The difference in medians from the time of arrival to medication administration was 24.6 min (95% confidence interval [CI] 21.3 27.9 min). All other components of this time interval were also significantly different (p < 0.01) (Table 2 and Figure 3). Median pain score for afebrile children was significantly higher as compared with the febrile children, with a pain score of 6 (interquartile range [IQR], 5 8) for afebrile children vs. 3 (IQR, 0 6) for febrile children (median difference = 2; 95% CI 2 3; p < 0.01). A five-tiered triage category was used, with the lowest number having the greatest acuity (9). The median tier was 3 for both the febrile and afebrile groups. Patient demographics except for age and race were similar (Table 1). Fewer febrile patients tended to be white, as compared with afebrile patients (44.3% vs. 53.7%). When times to medication administration by age (Table 3) and acuity (Table 4) were stratified, patients with fever were always treated more promptly than those that were afebrile. Young febrile children were treated more quickly than older febrile children. A separate secondary analysis was used to determine the individual effects of temperature, pain, age, and
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Figure 2. Flow of patient visits that were analyzed during the 1-year study period. ED = emergency department.
acuity on the time to treatment. The central 80% of data by time to treatment was found to be approximately normally distributed. A multiple linear regression analysis on the central 80% of these data was performed. The regression analysis of variance with time to treatment as dependent was statistically significant (F2361 = 31.45; p < 0.001) using all predictors. Three of four coefficients were significant: temperature elevation, acuity, and age (all, p < 0.01). Pain scale was not a significant predictor for time to treatment. To provide relatively unbiased determination of correlations, the partial correlation between variables was determined. The partial correlation is the correlation between variables ignoring the contribution of other variables. The partial correlation of time to drug administration with the temperature elevation was statistically significant (rpartial = 0.105; p < 0.01), but the partial correlation of time to drug administration using the pain scale was not statistically significant (rpartial = 0.03; p = NS). Age was also correlated with time to treatment (rpartial = 0.101; p < 0.01) as well as acuity (rpartial = 0.07; p < 0.01). This analysis is consistent with the finding that time to drug administration was more strongly correlated with fever, age, and acuity than with pain.
DISCUSSION It has been shown that fever phobia contributes to undue concerns about elevated temperature and others have shown that oligoanalgesia is a significant problem (1,6,10 14). The study looked at the effect of these well-described concerns on the time to treatment and found a large and significant difference between the two groups. The combination of undue concern for temperature elevation and insufficient concern for the treatment of pain possibly had a cumulative effect and may have contributed to the large time disparity between the two groups. Oligoanalgesia can have adverse consequences for patients of all ages. Although outside the scope of this study, infants circumcised without anesthesia exhibited stronger pain responses to subsequent routine immunizations during the first 6 months of life than infants who were not circumcised, suggesting that pain might exert long-term effects on infant behavior. Inadequate treatment of pain in children has been noted to increase pain ratings during subsequent procedures (13,14). In a study that evaluated out-of-hospital administration of analgesics, one third of parents who did not administer analgesics to their
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Table 1. Patient Demographics
Characteristic Age (years) (SD) Sex (% female) Race (% white)
Temperature <100.4 F Temperature $100.4 F (n = 1861) (n = 1097) 11.9 (4.8) 52.1 53.7
6.9 (4.1) 53.2 44.3
SD = standard deviation.
children thought that giving analgesics would be harmful (15). Adolescents have been described as most vulnerable to experiencing unrelieved pain (5). It has also been noted that when pain is not promptly treated in young adults, there is a higher incidence of post-traumatic stress disorder (6). Fever is the single most common nontrauma-related reason for a visit to the pediatric ED (16). There is no information in the literature to suggest that treating a fever in pediatric patients has any beneficial effect on morbidity. However, there are parental concerns about the need to treat fever promptly (11,12,17). There is also misguided concern that untreated fever can cause seizures (18 20). Physicians themselves have recommended prompt treatment of fever, despite there being some evidence to the contrary (21). Fever can enhance body defense mechanisms during infection (4). Some bacteria have growth inhibition at higher temperatures. Human lymphocytes have increased metabolic activity and leukocytes exhibit increased phagocytic activity at moderate temperature elevations (3). It has been suggested if children are tolerating their fevers well, without irritability, lethargy, or delirium, perhaps care providers should not remove a potential host defense mechanism by giving antipyretics (4). Although there are various mechanisms to determine pain for infants and children, the study was designed to
analyze those 3 to 19 years of age because of their ability to better verbalize their pain. If patients younger than 3 years of age were included, the disparity would have been greater by approximately 7 min. Although there are validated methods of measuring pain in the 0 to 3-year age range, the study was designed specifically to address concerns that these methods might not be universally used in one area that triages both pediatric and adult patients (22,23). Part of time-to-treatment discrepancies between fever and pain might be the tendency to best treat what can be quantified. Temperature is objectively measured and reliably lowered by treatment, bringing a sense of accomplishment to the caregiver, even though objective improvement of the temperature might not correlate well with patient outcomes. Pain scales, on the other hand, are harder to measure and changes are harder to objectively assess (24). Pain in children has sometimes been trivialized in older literature that suggests that children to not remember pain. Pain might be undertreated due to inexact measurement and outmoded notions that prompt treatment is not important (25). In this study, fewer febrile patients tended to be white as compared with afebrile patients. Perhaps younger children tended to be non-white as compared with older children with elevated temperatures, as fever phobia seems to vary by ethnicity (26 28). There was an assumption that the primary purpose for administering these drugs in the febrile child was for the treatment of fever, although pain could have been present also. There was a significant difference in the median pain score reported in the febrile vs. afebrile group. The findings demonstrate that priorities for treating pediatric emergency patients with acetaminophen and ibuprofen are seemingly reversed. The reasons for this disparity are not answered by the data. In all the time intervals we measured, there was a significant difference
Table 2. Time Component Intervals to Medication Administration Median Time to Medication Administration (min) (IQR)
Median Interval (min) Interval
Temperature <100.4 F (n = 1861)
Temperature $100.4 F (n = 1097)
Difference Between Medians*
Arrival to medication administration Bed assignment to medication administration Vital signs to medication administration Medication order to medication administration
83.2 80.2 76.3 8.0
54.0 51.5 46.5 7.1
24.6 24.9 24.6 0.9
95% CI* 21.3 21.6 21.4 0.4
27.9 28.3 27.9 1.3
IQR = interquartile range. Median times to medication administration from patient arrival, bed assignment, vital signs obtained, and medication ordered for the administration of either acetaminophen or ibuprofen are given. Median time to medication administration for febrile patients was shorter for each group (p < 0.01 for all groups). * As determined by the Mann-Whitney U test StatsDirect (Cheshire, UK).
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Figure 3. The median time intervals for afebrile vs. febrile patients for medication administration from arrival (83.2 vs. 54.0 min), bed assignment (80.1 vs. 51.5 min), vital sign documentation (76.3 vs. 45.6 min), and medication order (8.0 vs. 7.1 min), along with interquartile intervals (IQ). IQ3 = 3rd quartile; IQ1 = 1st quartile.
with febrile children getting medication sooner. When differences for each age group and for each acuity classification were analyzed by both stratification and by examining partial correlations, the disparities were found to be similar, thus arguing against bias by confounding variables. There have been ED practices that make pain management a high priority by establishing treatment guidelines; measuring practice outcomes and education does produce changes in the attitudes and practices of care providers and improve patient satisfaction (29,30). There might be a continued misperception by children’s caregivers that prioritizes antipyresis over analgesia.
Although we do not advocate withholding antipyretics, we do advocate timely management of pain. Limitations This was a retrospective study and can only demonstrate an association rather than a causal relationship. This study was performed at only one hospital, which limits the ability to generalize the results to other settings. The study did not specifically determine what influenced the health care provider to prescribe a medication, nor was the diagnosis ascertained for each patient. Certainly, some of the febrile patients did report some
Table 3. Stratification by Age No. of Patients in Each Age Group
Median Time to Medication Administration (min)
Age (years)
Temperature <100.4 F
Temperature $100.4 F
Temperature <100.4 F
Temperature $100.4 F
$3 to <6 $6 to <9 $9 to <12 $12 to <15 $15 to <19 $3 to <19
311 277 273 346 654 1861
647 202 99 61 88 1097
77.4 81.2 74.7 82.8 94.9 83.2
51.5 54.9 55.1 56.1 66.1 54.0
Median times from patient arrival to the administration of either acetaminophen or ibuprofen are given for each age group along with the number of patients in each age group. Median time to medication administration for febrile patients was shorter for all age groups (p < 0.01).
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Table 4. Stratification by Acuity Number of Patients in Each Acuity Group Acuity 2 3 4 5 All
Temperature <100.4 F
Temperature $100.4 F
244 1329 283 5 1861
142 940 14 1 1097
Median Time to Medication Administration in Minutes (IQR) Temperature <100.4 F 87.1 (54.5 88.0 (56.0 64.5 (43.3 50.2 (42.0 83.2 (52.7
151.3) 141.9) 102.0) 59.0) 136.1)
Temperature $100.4 F 45.5 (31.3 55.2 (36.3 53.5 (42.9 28.9 (28.9) 54.0 (35.4
83.7) 89.8) 73.9) 89.3)
IQR = interquartile range. Median times from patient arrival to administration of either acetaminophen or ibuprofen are given for each acuity group along with the number of patients in each acuity group. Median time to medication administration for febrile patients was shorter for acuity groups 2 to 5.
pain. Some patients had both pain and fever and were included in the fever category. Eliminating these patients did not appreciably alter the results. Other factors might be related to the timing and decision to administer acetaminophen or ibuprofen, such as abnormal vital signs, ED prioritization system, time of presentation, etc. The study was not designed to analyze these factors. Patients who received opioids for their pain were not included and therefore patients with the most severe pain may have been excluded. Opioids administered were almost always oral codeine or i.v. morphine. There were relatively few instances of oral opioids (as most extremity fractures and lacerations were treated in the Fast Track area and not in the pediatric ED). Intravenous opioids were given only after i.v. access was obtained and the time to i.v. access was most often >60 min. Including patients that received opioids would not have affected the overall results. The study did not provide any data on the type of pain or response to treatment. It was not designed to determine whether pain was adequately treated and if the patient might have required a controlled substance for analgesia. The level of oligoanalgesia was not elucidated. It is theoretically possible that adequate pain control was already provided to the ED patients. However, we were unable to find any mention in the literature of instances where there was overtreatment or overmedication for pain in the ED, and we have no reason to believe that the practice pattern in our ED differs in this regard. The results could be influenced by variations in individual provider practice, and the study did not control for the effect of clustering by individual providers. Providers see patients on a next-patient basis and do not choose the next patient to be seen, thus minimizing this type of selection bias. CONCLUSIONS Pediatric patients are treated sooner with acetaminophen or ibuprofen when presenting with fever than those who
do not have a fever but do have pain. We believe this difference is associated with continuing and prevailing unnecessary concerns about fever and the prevalence of oligoanalgesia, the undertreatment of pain.
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ARTICLE SUMMARY 1. Why is this topic important? Undertreatment of pain is a persistent problem with the potential for adverse effects. Fever may be treated with a higher priority than pain in the pediatric emergency department population. 2. What does this study attempt to show? Our primary objective was to assess whether patients with a fever are treated more promptly with acetaminophen or ibuprofen than those without a fever. 3. What are the key findings? Our study found that patients with fever are treated more promptly than those with pain. 4. How is patient care impacted? There appears to be an inherent tendency to treat fever sooner than pain. The combination of undue concern for temperature elevation and insufficient concern for the treatment of pain may have a cumulative effect and may have contributed to a time disparity between the two groups.