Columns, Patient Care

Pediatric Opioid Pain Management Lacks Improvement

Issue 3 and Volume 42.

The Research

Browne LR, Shah MI, Studnek JR, et al. Multicenter evaluation of prehospital opioid pain management in injured children. Prehosp Emerg Care. 2016;20(6):759–767.

The Science

Recognizing that the rate of opiate administration to pediatric patients was low, in the fall of 2014, three large ALS services—Houston Fire Department, Milwaukee County EMS and Mecklenburg EMS—made changes to their protocols to match the evidence-based recommendations from the National Association of EMS Physicians position statement and the EMS for Children guidelines. They provided mandatory education with the intent to improve the appropriate administration of opiates to children with traumatic injuries.

Data extracted from the prehospital care reports was reviewed for the 10 months leading up to and following the changes. Similar numbers of children in pain were transported in both periods (3,597 vs. 3,743). Pain scores were documented in 18% of pediatric patients both before and after the changes. During both periods, when pain was assessed, 74% of the children were rated as having moderate-to-severe pain. The rate of opiate administration remained unchanged at 5%.

Medic Wesley Comments

This study and outcome have me intrigued. It’s a perfect example of measurement before and after training and education. Most often we see a move toward a more favorable outcome, but this study showed that even after educating EMS providers, they were still likely to withhold pain medication to pediatric patients.

The reason certainly isn’t lack of caring on the part of these providers. I am personally familiar with one of these three services and I can tell you they’re patient advocates and their medical direction is quality-based.

Despite permission and encouragement to better treat pediatric pain, there was no change in care. I feel that it’s confusion with the pain scales for rating pain in non-verbal pediatric patients and comfort in dealing with pediatric patients in general.

One option for education might be a clinical rotation in pediatrics that would present the EMS providers with frequent opportunities to assess pediatric patients. Perhaps confidence could grow by working side-by-side with pediatric-care professionals.

I suspect that the reasons for the startling outcome of this study lies within the minds, and not the hearts, of many of the providers.

Doc Wesley Comments

I’m familiar with all three agencies in this study. The desire to improve patient care through the use of evidenced-based protocols is the cornerstone of their medical direction. However, despite their well-intentioned efforts, the quality of care for children in pain was in vain. Why?

With all due respect to these services, I’ll suggest several possible reasons for their failure. The first is size. Each has several hundred to thousands of providers; simply changing protocols, despite providing one-time education, rarely changes behavior or outcomes in large services. Constant and continuous feedback through quality improvement and frequent refresher education are the keys to any successful initiative. Doing this in a large service becomes logistically difficult.

The second is acceptance—not only acceptance by the EMS provider, but acceptance by the receiving ED. The EMS provider ambushed by an upset ED nurse or physician for “over-sedating” a child with a broken arm is unlikely to adopt a proactive opiate strategy. It’s difficult to get buy-in from every ED a large EMS agency serves.

The third is related to pediatric pain scores. There’s no single scoring method that works reliably with all ages. Perhaps the goal for pediatric pain control should be limited to ages 6 and older for whom variations on the Baker-Wong FACES scale have been shown to be valid. The authors of this study didn’t provide details as to differences in care by specific age ranges, but instead lumped all patients under the age of 18 into the pediatric protocol.

Finally, to treat pain you must measure it. As the saying goes, “You can’t treat a fever if you don’t take a temperature.” While all three service saw an increase in pain assessments, my experience is that unless you make the pain score mandatory on every patient, you can’t learn where you should concentrate any improvement efforts.

Despite these criticisms, I applaud the authors for publishing a study that some would consider negative since their program failed to improve care. These studies often tell us more about what doesn’t work than those with multiple interventions and positive outcomes.