Prehospital Pediatric Pain Management: Continued Barriers to Care

    Prehospital Pediatric Pain Management: Continued Barriers to Care Sarah A. Mellion, Kathleen Adelgais PII: DOI: Reference:

S1522-8401(17)30067-8 doi: 10.1016/j.cpem.2017.09.007 YCPEM 638

To appear in:

Clinical Pediatric Emergency Medicine

Please cite this article as: Mellion Sarah A., Adelgais Kathleen, Prehospital Pediatric Pain Management: Continued Barriers to Care, Clinical Pediatric Emergency Medicine (2017), doi: 10.1016/j.cpem.2017.09.007

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ACCEPTED MANUSCRIPT Prehospital Pediatric Pain Management: Continued Barriers to Care

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Sarah A. Mellion, MD (corresponding author) Clinical Instructor Section of Pediatric Emergency Medicine Children’s Hospital Colorado/University of Colorado Denver Conflicts of Interest: none 13123 E. 16th Ave, Box B251 Aurora, CO 80045 [email protected] Phone: 303-724-2578 Fax: 720-777-7317

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Kathleen Adelgais, MD, MPH Associate Professor Section of Pediatric Emergency Medicine Children’s Hospital Colorado/University of Colorado Denver Conflicts of Interest: none [email protected] Phone: 303-724-2578 Fax: 720-777-7317

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Abstract Painful injuries and illnesses are common conditions that activate emergency

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medical transport. The assessment and treatment of pediatric pain is integral to

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prehospital patient care. Several studies have reported that pain is often under recognized and undertreated in the prehospital setting, particularly in children. The

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objective of this article is to describe the current state of prehospital pediatric pain

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assessment and management, as well as to discuss potential avenues to improve

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prehospital patient care.

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Key words: emergency medical services, prehospital, pain management, children,

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pediatric

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Recognition and management of pain are fundamental components of prehospital care in the pediatric patient. Between 25 and 50% of calls to emergency medical

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services are for children with traumatic injuries.[1-8] Despite its prevalence, pain is

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frequently undertreated.[6, 9, 10] In patients with painful conditions, failure to treat pain may lead to negative outcomes. Primarily, there is a delay in pain relief

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for the patient.[11, 12] Studies show that inadequate treatment of pain in children

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can also lead to post traumatic stress disorder (PTSD), physiologic and psychological changes in pain behavior responses, and a reduced response to

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appropriate weight based dosing of analgesia.[13-16] Given the importance of pain management in acutely ill and injured pediatric patients as well as recognized

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disparities in treatment, initiatives and guidelines have brought attention to this

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deficit.[17-20] In particular, the National Highway Traffic Safety Administration

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(NHTSA) recently supported an evidence-based guideline for traumatic pain management (Figure 1).[18] It is important for pediatricians and emergency

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medicine providers to support the prehospital practice of pediatric pain management by emergency medical services (EMS) providers with adequate medical oversight.

CURRENT STATUS OF PREHOSPITAL PAIN MANAGEMENT Pain Assessment One of the first considerations in establishing a prehospital protocol for pain management is the choice of pain scales to measure pain severity in children. To date, no pain scale has been validated for use in the prehospital setting. As a result,

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the choice of pain scales has been limited to those that have been previously validated in the hospital setting. The pediatric pain scales in use were developed for

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research purposes to allow providers a way to measure procedural pain and to

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compare treatments.

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Pain scales fall into 2 general categories: observational-behavioral and self-report.

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Observational-behavioral scales require the provider to assess the patient on multiple behaviors and rank them. These were designed to assess the younger child

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who does not have the ability to report his or her own pain. Although training is required for the administration of observational-behavioral scales, they do have

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good inter-rater reliability. Commonly used scales are the Faces, Legs, Activity, Cry,

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Consolability (FLACC) scale for patients aged 0-7 years and the Children’s Hospital

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of Eastern Ontario Scale (CHEOPS) in patients 1-7 years. In self-report scales, children are given a scale and then asked to indicate their degree of pain using the

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scale. These scales have varying representations of pain including cartoon or photos of faces, a changing color scheme, or a line from 0 to 10 or 100. The Faces Pain Scale Revised (FPS-R) and the Wong Baker Faces (FACES) are often used for patients 4-12 years of age. Lastly, there is the numeric reporting scale (NRS), which has been recommended for children 12 years or older.

Studies have demonstrated that the introduction of a pain scale to prehospital providers will improve documentation of pain scores in their patients.[21, 22] One of the challenges for monitoring trends in prehospital pain management is the

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ability to translate pain scale measurements to a data point that can be tracked in EMS run sheets, electronic patient care reports, and EMS registries. For example,

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the FPS-R has six pictures to choose from, allowing for each face to represent an

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even number between 0 and 10. The CHEOPS scale, however, is a 9-point scale with a range of 4 to 13, and as a result, it does not translate to the typical 0-10 point scale.

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Most EMS registries and patient care reports have a field to document the pain

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score, and many have a field to note the type of pain score utilized, however, this may not necessarily be required of agencies submitting data. Although the data

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dictionary for National EMS Information System (NEMSIS) does include a field for pain score, it does not include a field specifying the type of pain scale utilized,

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making data collection and interpretation challenging. One study of the Arizona

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Pre-hospital Information and EMS Registry (AZ-PIERS) found that pain scores are

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incompletely documented, as are contraindications to opiate analgesia, thus making quality improvement initiatives designed to assess compliance and correct use of

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the pain scale difficult.[23]

Medication Options and Delivery Modalities Researchers have continued to explore the use of medications and modalities to identify treatment options that would be ideal for the prehospital setting. Fentanyl and morphine remain the most common treatment options, with increasing research into prehospital ketamine.

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Prehospital use of fentanyl has increased over time and advocates state that it may be ideal for use in this setting for several reasons. First, it has a short half-life,

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resulting in rapid onset and relief of discomfort; however, it also provides a shorter

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period of pain relief. Given the frequently reported concern that prolonged pain control after arrival to an emergency department will obscure the underlying cause

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of pain, the short time of fentanyl’s action may actually be a positive feature in this

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setting. Kanowitz studied 2,129 adult patients who received fentanyl for prehospital analgesia and found only 12 (0.6%) had a vital sign abnormality that

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could be related to fentanyl. In their study, there were no admissions to the hospital and no patient deaths due to intranasal (IN) fentanyl.[24] They noted a significant

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decrease in pain scores from 8.4 to 3.7 and concluded that fentanyl can be used

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safely and effectively for pain management in the prehospital setting.

Another feature of fentanyl useful in the prehospital setting is its ability to be

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absorbed through the mucous membranes; there are reports of easy administration intranasally, via nebulizer, and even through the buccal mucosa. This allows for analgesia in patients without intravenous (IV) access, a particularly attractive feature in pediatric patients. Karlsen and colleagues examined the overall safety of IN fentanyl in a prospective study of 903 adults and older children (age > 8 years) who were treated for orthopedic injuries, abdominal pain and chest pain in the prehospital setting. Patients received 1 to 3 doses of either 50 or 100 mcg. They found 4% of patients had mild side effects including mild hypotension, nausea,

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vomiting, and vertigo with a mean reduction in pain score of 3 points and concluded

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that prehospital administration of IN fentanyl is safe and effective.[25]

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The effectiveness of fentanyl has also been compared to the more traditional treatment, morphine. Smith et al compared prehospital IV fentanyl and morphine in

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adults, and found no statistical difference in analgesic effectiveness.[26] Rickard

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compared IV morphine to IN fentanyl in 258 adult patients requiring prehospital analgesia for both cardiac and non-cardiac indications and found no difference in

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overall effectiveness.[27] Bendell et al studied the effectiveness of IV morphine compared to IN fentanyl, both in combination with inhaled methoxyflurane for

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managing moderate to severe pain in 3,312 pediatric patients aged 5 to 15 years.

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They found effective analgesia was achieved in 82.5% of cases overall with no real

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difference between IV morphine and IN fentanyl. There was no evidence that combination analgesia with methoxyflurane was better than either fentanyl or

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morphine alone.[28]

Other options in prehospital analgesia have been studied. The availability and indications for ketamine, a dissociative agent that has analgesic effects, has been growing exponentially in the prehospital setting. The majority of studies have been in the adult population and there are limited reports of ketamine administered to pediatric patients by paramedics. Johansson examined the role of low dose ketamine in combination with morphine for adult patients with long bone fractures in the prehospital setting. He found a greater reduction in pain scores among

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patients who received the two medications in combination, with a reduction in the dose of morphine used.[29] There were no differences in nausea or vomiting;

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however, there was an increase in blood pressure among those receiving ketamine.

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Intranasal administration of ketamine has also been reported. In a 9-patient case series of trauma patients cared for in the winter outdoors, investigators found a

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significant reduction in pain score.[30] Bredmose examined ketamine for

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prehospital care in a pediatric trauma population. In their study, 164 trauma patients aged less than 16 years were cared for by a physician-led flight team and

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received either 1 mg/kg IV or 4 mg/kg intramuscular (IM) of ketamine. The

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investigators reported that there was effective analgesia and no adverse events.[31]

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Multiple delivery modalities are available in the prehospital setting. Historically,

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morphine has been administered IV as well as IM. While IV administration of opiates remains the conventional approach, the IN route is receiving increasing

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popularity. The use of the mucosal atomizer device (MAD) allows for the administration of weight based IN doses of a medication, which allows for a more appropriate dose for younger children than traditional metered dosing such as in nasal sprays.[33] One of the hopes with the use of the mucosal atomizer is that it would facilitate analgesia interventions in the out of hospital setting. O’Donnell studied 946 pediatric trauma patients before and after the MAD was introduced into their protocols. They found no difference in frequency of use of fentanyl in patients meeting criteria for prehospital analgesia before or after the MAD (30.4% vs.

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37.8%). They did observe that 36% of the patients treated with fentanyl after the

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MAD was introduced received it by the IN route.[34]

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Outside the United States, oral analgesia continues to be utilized in the prehospital setting. In a study from Ireland, among 2635 children transported in a 12-month

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period to one of four emergency departments with a documented symptom of pain,

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approximately one-fourth received some form of analgesia, most commonly oral acetaminophen (35%) or ibuprofen (23%) as a single agent. Only 12% of children

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with documented severe pain received oral or IV morphine. Additionally, 11% of children received inhaled nitrous oxide.[10] Adult studies of prehospital inhaled

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nitrous oxide have demonstrated its efficacy for the treatment of pain.[32]

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BARRIERS TO PREHOSPITAL PAIN MANAGEMENT Initial studies examining the frequency of prehospital pain management found rates

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to be quite disparate. Hennes found that 3% of children with fractures and 8% of children with burns received prehospital analgesia, while Swor noted that treatment was as high as 21% in children with extremity fractures.[2, 3]

Given the known disparities in pain management, many organizations called for research into improving prehospital pain management. Hennes surveyed 155 paramedics, and found significant disparity between pediatric and adult patients. The barriers reported were the inability to assess pain, difficulty in obtaining intravenous access, and a fear of complications. When they compared prehospital

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provider perceptions of treatment to actual treatment, they found that they frequently over estimated their treatment of pain in the prehospital setting,

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sometimes in upwards of a ten-fold difference.[3]

Parrish et al administered a survey to 280 paramedics, and reported that more than

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half of providers had received formal training on pediatric pain scales and had

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protocols for assessment and treatment of pain in children. However, more than two-thirds of providers reported less than moderate comfort measuring pain

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severity in children. Pain assessment was more likely to be recorded with a severe mechanism of injury. In pediatric patients with painful conditions, 47% of

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participants reported using the Numeric Rating Scale. After an education module

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was administered describing pediatric pain scales, 85% of providers stated that

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they would be more than somewhat likely to use the Numeric Rating Scale in the

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field.[23]

There is evidence that the increased attention to pain management may be leading to improved rates of analgesia administration in the field in some systems. A study of the implementation of a new protocol for pain treatment based on an evidencebased guideline in the Maryland EMS system demonstrated an overall rate of narcotic medication administration of 70% for patients with traumatic conditions transported by advanced life support (ALS) providers. The same study demonstrated no disparities in the rate of administration of pain medications by age or gender.[35]

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Reports on the results of focus groups have identified certain prehospital provider

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belief systems along with reported enablers and barriers to pain treatment.

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Enablers of pediatric pain management included having good online medical control and the availability of guides to assess pain severity. Additional barriers to those

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previously reported included unwanted attention from authority figures, the overall

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culture of parsimony in medication administration and finally, the perceived superiority of hospital care.[36] This is despite studies that demonstrate that the

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deferral of pain management to the receiving facilities delays pain treatment by up to 90 minutes.[11] Additionally, those in the focus group reported the need for

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offline medical direction to eliminate the barrier of needing to call for online

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medical direction to administer pain medications. Walsh et al also performed focus

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groups, in which providers expressed concern for complications related to aggressive treatment with opioids without significant objective signs, not knowing

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the end point of treatment, masking diagnostic symptoms, and patient malingering.[37]

More recently, Murphy et al found that 41% of pediatric patients transported by EMS reported pain as their primary symptom, and 32% had a documented formal pain assessment.[10] Younger age, short transfer time to the ED, and calls between midnight and 6 AM were less likely to have a documented pain assessment. Twentysix percent of patients received analgesia prior to ED arrival.[10] Galinski et al

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reported similar findings, in which 42% of prehospital patients had documented

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pain, and 51% of patients experienced pain relief.[6]

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While there has been increasing advocacy to improve prehospital care, Browne et al demonstrated that despite implementing prehospital pain treatment

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recommendations, only 25% of children had a documented pain score. Patients

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with a documented pain score, however, were two times more likely to receive opioids compared to those without a pain score documented (18% versus 9%).[38]

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In addition, they found that children with longer transport times and successful IV placement were more likely to receive prehospital analgesia.[38] In another study,

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Browne et al again reported prehospital pediatric opioid administration to be low

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after pain protocol implementation, with 18% of patients having a documented pain

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score and 5% receiving opiates.[39] This is consistent with Brown et al, who found that despite pain management protocol implementation, there was no change in the

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percentage of patients with a documented pain score or the administration of morphine, but there was an increase in dosing of narcotics.[35]

Given the reported barriers and attitudes toward pediatric prehospital pain management, investigators have also examined the role of prehospital provider selfefficacy. Jaeger et al followed 142 prehospital providers over a 13-month period after the introduction of a prehospital pain protocol in their agency. The investigators measured reports of self-efficacy in pain management for three theoretical age groups. They found baseline reports of self-efficacy to be very low

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for several pain management tasks including pain assessment, recognizing the correct dose, and administering the dose. Not surprisingly, the self-efficacy

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reported was lowest for the youngest patients. The investigators found an increase

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in self-efficacy across age groups after introduction of the pain protocol. More importantly, they found that there was retention of the improved self-efficacy over

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the 13-month period, particularly for pain score assessment. Concurrently, they

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found a significant increase in pain score documentation in the EMS registry after the protocol was introduced, correlating with the strongest retention of self-efficacy

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for the task of pain score assessment. However, despite this change in practice, there was no change in frequency of medication administration over the study

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period.[21]

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Quality Improvement and Monitoring at a Statewide Level To date, numerous research studies demonstrate that among EMS agencies, protocol

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change with education does not automatically result in a change in practice.[38, 39] One way for state EMS systems to pursue practice change is through statewide protocols. Overall, there is significant variability among states with regard to EMS protocols; some have mandated statewide protocols, others have model protocols to be adapted by individual agencies; and finally, some states simply have EMS agencies write their own protocols such that their providers are practicing in compliance with state licensure requirements.[40] The benefit of mandated protocols at the state level is that one standard of care is expected and can be tracked.

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There is now some limited evidence on the impact of mandated protocols on

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traumatic pain management. In the state of Maryland, where mandatory protocols

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exist, investigators found that after the implementation of an evidence-based guideline for traumatic pain management there was no difference in the proportion

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of patients treated for pain, but there was an increase in the doses administered to

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patients less than 15 years of age.[35]

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Dissemination of statewide guidelines for pain management is not as straightforward among states without mandated protocols, however. In 2014, the

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National Association of State EMS Officials (NASEMSO), in a cooperative agreement

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with NTHSA, worked with 5 states to advance the evidence-based guideline for

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traumatic pain management with a goal of examining barriers and facilitators to the process.[41] Overall, numerous challenges were found including the lack of a

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standardized way to track pain management and elements of the guideline including pain scores, medication routes, and presence of contraindications. Specifically, challenges existed at both the state level with regard to the ability to track key elements of the guideline in a statewide database, as well as at the agency level where certain challenges, such as the need to restock medications from hospitals, served as a significant barrier. Finally, despite the presence of learning management systems in all states where training on the guideline could be viewed, uniform training could not be tracked. Overall, feedback from the states identified

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that the focus on pain management was seen as positive, but large barriers still exist

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on implementing pain management at the local level.

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Prior efforts at practice change that have not resulted in significant improvement in pain management suggest that different tactics may be necessary. For example,

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benchmarking and feedback to personnel are important parts of any quality

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improvement program and may have a role in efforts to improve pain treatment within EMS systems. Quality improvement methodology does, however, have

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certain requirements including the infrastructure to capture and measure baseline data, perform qualitative analyses that identify process and system issues that can

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be targeted for change, as well as the ability to do follow-up assessments and

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provide feedback to personnel. This infrastructure is necessary to perform standard

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Quality Improvement efforts using the “Plan, Do, Study, Act” or PDSA framework.[42] At this time, four of the federal EMS for Children Program’s

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Targeted Issue grants are funding quality improvement focused projects, three based in EMS systems.[43] One project in North Carolina will use a focused program of education and performance improvement feedback tools targeting EMS care in three conditions including trauma care. In addition to disseminating a performance improvement program, the project will also assess benefits and barriers to the use of feedback reports given to EMS providers. This project will provide important information regarding the potential role of quality improvement methods to improve care in EMS systems and can hopefully be applied to the area of prehospital pain management.

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SUMMARY

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The assessment and execution of prehospital pain management remains suboptimal.

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Some studies have suggested that targeted education and protocol implementation has improved prehospital pediatric pain management, however, deficits still exist.

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Quality improvement methods may have a role in improving prehospital pain

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management for children.

4. 5. 6. 7. 8. 9. 10. 11. 12.

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Figure 1. NHTSA Evidence-based guideline for traumatic pain management.[18]

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