Pre-hospital pain management in children
Research type
Research Study
Full title
What are the predictors, barriers and facilitators to effective management of acute pain in children by ambulance services?
IRAS ID
243022
Contact name
Gregory Whitley
Contact email
Sponsor organisation
University of Lincoln
Clinicaltrials.gov Identifier
CRD42017058960, PROSPERO Mixed Methods Systematic Review
Duration of Study in the UK
2 years, 4 months, 4 days
Research summary
Summary of Research
Background
Children suffer pain for a variety of reasons, for example when they injure themselves through broken bones, dislocations, wounds or burns. When a child is in pain, the ambulance service is often involved to take the child to hospital and it is the ambulance clinician’s role to manage the pain. Studies have shown that the management of pain for children in the ambulance service is poor. A recent United Kingdom study found that of injured children who reported pain to an ambulance service (n=7483) 38.8% received no treatment. In the United States one study found that from 55,642 pre-hospital patients aged <19 years, 42.1% suffered a traumatic injury or pain, yet only 0.3% received analgesia.Aim
The aim of this study is to identify how pain is managed in children attended by a UK ambulance service, to explore factors associated with effective or ineffective pain management, and to investigate ways to improve this.Methods
We would like to perform a study that reviews a sample of clinical records of children in pain. This would include all patients under the age of 18 years. The factors which could affect their treatment, such as age, gender or injury type would be identified and analysed in greater detail. This would include factors that both help and hinder the pain management process. Once these factors have been determined, we would like to interview paramedics and emergency medical technicians who would help to explain these factors and what they think might influence the treatment process. We would also like to explore how pain management could be improved. Cultures, beliefs and perceptions about pain relief in children of paramedics and emergency medical technicians will be explored during the process. This study will take approximately three years to complete.Summary of Results
Background Pain is a highly complex sensory and emotional experience; the biological, psychological and social aspects must each be considered. The intersection between the phenomenon of pain, the unpredictable pre-hospital environment and children is highly convoluted. Studies have shown that pre-hospital pain management in children is poor, despite access to pain management being considered a fundamental human right. Without effective pain treatment, children may suffer long-term psychological changes (e.g. altered pain perception) and are at risk of developing post-traumatic stress disorder. The aim of this thesis was to identify predictors, barriers and facilitators associated with effective pre-hospital pain management in children suffering acute pain and to identify ways to improve the quality of care.Results
The systematic mixed studies review included 13 studies (8 quantitative and 5 qualitative) and highlighted the importance of analgesic administration. The initial quantitative study included 2312 clinical records; only 39% of children suffering acute pain achieved effective pain management. Predictors of effective pain management included children who were younger, administered analgesics, attended by a paramedic or living in an area of low or medium deprivation. The final qualitative study included 12 ambulance clinicians (9 paramedics and 3 emergency medical technicians) who provided possible explanations for these disparities. Novel barriers and facilitators were also identified along with ways to improve pain management. Meta-inferences were developed which provided a more comprehensive understanding of this complex phenomenon. To improve pre-hospital pain management in children, the following recommendations were made; 1) explore methods to increase rates of analgesic administration, perhaps by utilising the intranasal and inhaled route; 2) reduce fear and anxiety in children, perhaps by using child friendly uniform, non-pharmacological techniques and more public interaction and 3) reduce fear and anxiety in clinicians, by enhancing training, optimising crew mix and developing a more pragmatic pain assessment tool. A theoretical model of pre-hospital pain management in children was developed as part of this thesis.Conclusion
Pre-hospital pain management in children may be improved by increasing rates of analgesic administration and reducing the fear and anxiety experienced by children and clinicians. Future research should explore the experience of the child and determine the most important outcome measures. Robust clinical trials are needed to determine the efficacy and safety of intranasal (fentanyl/ketamine) and inhaled (methoxyflurane) analgesics in the pre-hospital setting. Investment in future research and intervention development is imperative; we need to make children’s pain in the pre-hospital setting matter.REC name
HSC REC B
REC reference
18/NI/0120
Date of REC Opinion
19 Jun 2018
REC opinion
Favourable Opinion