CLINICIAN'S CAPSULEWhat is known about the topic?Children's pain in the emergency department (ED) continues to be under-recognized and sub-optimally managed.What did this study ask?We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED.What did this study find?Of the 743 children who presented to the ED with a painful condition, 408 (54.9%) were offered analgesia. If offered in the ED, analgesia was accepted by 91% (373/408) of the caregivers/children.Why does this study matter to clinicians?This study suggests that caregiver/child refusal of analgesia is a not a major barrier to optimal pain management and highlights the importance of ED personnel in encouraging adequate analgesia.
Introduction: Intranasal ketamine (INK) has an emerging role for procedural sedation (PSA) in children in the emergency department (ED). While INK is less invasive and requires fewer personnel than IV ketamine, widespread adoption in the paediatric ED would require strong nursing acceptance. To inform INK implementation strategies, we explored nursing perspectives surrounding INK, including perceived barriers to its adoption. Methods: Nurses in the paediatric ED of London Health Sciences Centre, London, Ontario were recruited by email. Two, one-hour, in-person focus groups were conducted on January 26 and February 2, 2018 using a semi-structured interview format. Transcription was performed by a professional medical transcription service and analyzed using an inductive qualitative approach involving code words corresponding to recurring topics. Thematic analysis was used to group similar codes into themes. The analytic process was managed using the NVivo 11 software package. Results: Results: Eight nurses participated. All nurses were female and had a mean of 8.9 (range: 2.5 - 26) years of pediatric emergency nursing experience. Seven nurses had experience monitoring and administering INK to children for PSA. Five themes emerged: 1) attributes of INK, 2) INK effects on patients and families, 3) INK effects on health care providers, 4) INK effects on the ED environment, and 5) uncertainty regarding INK's effectiveness, predictability, and fit into institutional sedation protocols. Subthemes included 1) perceptions that INK produced a relatively shallower, slower-onset, and/or less titratable sedation, 2) the importance of patient cooperation (i.e. INK may be preferred by providers for older patients undergoing relatively painful or long procedures), 3) belief that INK was an effective anxiolytic and sedative with the potential to improve nursing resource utilization, and 4) belief that physician resistance to change and lack of personal familiarity were barriers to adoption. Conclusion: Conclusions: We identified clinical advantages to using INK in children, the importance of selecting appropriate patients, and barriers to widespread INK adoption. Importantly, our findings highlighted uncertainty about INK's effectiveness and incorporation into sedation protocols. Our findings will inform future knowledge translation strategies when implementing INK in the clinical setting.
Introduction: The suboptimal management of children’s pain in the emergency department (ED) is well described. Although surveys of physicians show improvements in providing analgesia, institutional audits suggest otherwise. One reason may be patient refusal. Our objectives were to determine the proportion of caregivers that offered analgesia prior to arrival to the ED, accept analgesia in the ED, and identify reasons for withholding analgesia. Our results will inform knowledge translation initiatives to improve analgesic provision to children. Methods: A novel survey was designed to test the hypothesis that a large proportion of caregivers withhold and refuse analgesia. Over a 16-week period across two Canadian paediatric EDs, we surveyed caregivers of children aged 4-17 years with an acutely painful condition (headache, otalgia, sore throat, abdominal pain, or musculoskeletal injury). The primary outcome was the proportion of caregivers who offered analgesia up to 24 hours prior to ED arrival and accepted analgesia in the ED. Results: The response rate was 568/707 (80.3%). The majority of caregivers were female (426/568, 75%), aged 36 years or older (434/568, 76.4%), and had a post-secondary education (448/561, 79.9%). Their children included 320 males and 248 females with a mean age of 10.6 years. Most (514/564, 91.1%) reported being “able to tell when their child was in pain”. On average, children rated their maximal pain at 7.4/10. A total of 382/561 (68.1%) caregivers did not offer any form of analgesia prior to arrival. Common reasons included lack of time (124/561, 22.1%), fear of masking signs and symptoms (74/561, 13.2%) or the seriousness of their child’s condition (72/561, 12.8%), and lack of analgesia at home (71/561, 12.7%). Analgesia was offered to 328/560 (58.6%) children in the ED and 283/328 (72.6%) caregivers accepted. The most common reason for not accepting analgesia was child refusal (20/45, 44.4%). Conclusion: Most caregivers do not offer analgesia to their child prior to arriving in the ED despite high levels of pain and an awareness of it. Despite high rates of acceptance of analgesia in the ED, misconceptions are common. Knowledge translation strategies should dispel caregiver misconceptions, and highlight the impact of pain on children and the importance of analgesia at home.
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