Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children.

OBJECTIVE: Children frequently present with head injuries to acute care settings. Although international paediatric clinical practice guidelines for head injuries exist, they do not address all considerations related to triage, imaging, observation versus admission, transfer, discharge and follow-up of mild to moderate head injuries relevant to the Australian and New Zealand context. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guideline for the care of children with mild to moderate head injuries presenting to acute care settings. METHODS: A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas - triage, imaging and discharge of children with mild to moderate head injuries presenting to acute care settings. We identified existing high-quality guidelines and from these guidelines recommendations were mapped to clinical questions. Updated literature searches were undertaken, and key new evidence identified. Recommendations were created through either adoption, adaptation or development of de novo recommendations. The guideline was revised after a period of public consultation. RESULTS: The GWG developed 71 recommendations (evidence-informed = 35, consensus-based = 17, practice points = 19), relevant to the Australian and New Zealand setting. The guideline is presented as three documents: (i) a detailed Full Guideline summarising the evidence underlying each recommendation; (ii) a Guideline Summary; and (iii) a clinical Algorithm: Imaging and Observation Decision-making for Children with Head Injuries. CONCLUSIONS: The PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children provides high-level evidence and practical guidance for front line clinicians.

National project seeking to improve pain management in the emergency department setting: findings from the NHMRC-NICS National Pain Management Initiative.

OBJECTIVES: The National Pain Management Initiative was established by the National Institute of Clinical Studies to improve analgesic practice across Australian EDs. METHODS: A barrier analysis provided information to better implement changes in analgesic practice. A working party was established and developed a multifaceted intervention strategy and clinical indicators. An online data collection system was developed and sites collected data at three monthly intervals for 18 months. A stepped-wedge design was chosen to manage the number of hospitals involved. Clinical indicators included documentation of pain score, time to analgesia, appropriate use of parenteral narcotics and effectiveness of analgesia for severe pain. RESULTS: A total of 16,627 patient datasets were entered from 45 metropolitan and regional hospitals. There was an increase from 41% to 64% in documented pain score (difference in proportions 23%, 95% confidence interval: 20-26) and median time to analgesia fell from 61 min (interquartile range: 23-122) to 41 min (interquartile range: 15-95). Appropriate parenteral narcotic use was over 90% for all time points combined. For all patients with severe pain there was no significant change in the proportion with a documented reduction of pain within 1 h of presentation. CONCLUSION: Significant improvements in documentation of pain score and time to analgesia were demonstrated through a national project of targeted improvement. Parenteral narcotic use has a high level of adherence to recommended practice. An improvement in the effectiveness of analgesia in severe pain has not been clearly demonstrated in this study.

Characteristics of effective interventions supporting quality pain management in Australian emergency departments: an exploratory study.

BACKGROUND: It is well established that pain is the most common presenting complaint in Emergency Departments. Despite great improvements in available pain management strategies, patients are left waiting for longer than 60min for pain relief on arrival to the emergency department. The aim of this study was to describe interventions that lead to successful implementation of the National Health and Medical Research Council approved guidelines Acute Pain Management: Scientific Evidence (2nd Edition) that include specific recommendations for best practice pain management. METHODS: A two-phased, mixed-method, exploratory study of all 52 Australian hospital emergency departments participating in the National Emergency Care Pain Management Initiative incorporating interview and document analysis was undertaken. FINDINGS: Interventions used by clinicians to improve pain management included nurse initiated analgesia, intranasal fentanyl for paediatric patients and lignocaine, and facio illiaca block. Education formed a major part of the intervention and the development of a working group of key stakeholders was critical in the successful implementation of change. Staff perceptions of patients' pain level and attitudes toward pain assessment and pain management were identified as barriers. CONCLUSION: This study highlighted how an effective framework to plan and implement practice change and tailored interventions, including education and training systems and products using the best available evidence, best equipped clinicians to manage pain in the ED.

Pain management in Australian emergency departments: current practice, enablers, barriers and future directions.

OBJECTIVE: To explore current pain management practice in Australian EDs and identify enablers and barriers for best-practice pain management. METHODS: Five focus groups and two in-depth interviews were held with ED clinical staff (n= 47) from six hospitals in three states. Participants were asked open-ended questions to determine current pain management practices, enablers and barriers to implementing best-practice pain management, and understand change in practice within the ED setting. RESULTS: Emergency department staff identified a gap between evidence-based pain management recommendations and everyday practice. Perceived barriers to improving pain management included a lack of time and resources, a greater number of urgent and serious presentations that place pain management as a lower priority, organizational protocols and legislative issues. All groups noted difficulty in applying pain management guidelines in the context of competing priorities in the challenging ED environment. A culture of learning clinical practice from respected senior staff and peers was perceived to be a key enabler. Participants consistently expressed the view that evidence-based practice improvement should be championed by senior clinical staff, and that evidence to demonstrate the benefits of change must be presented to support the need for change. CONCLUSIONS: Effective and sustainable system change requires a strategy that is initiated within the ED, targets opinion leaders, is supported by evidence, and engages all levels of ED staff.

Impact of pain location, organ system and treating speciality on timely delivery of analgesia in emergency departments.

OBJECTIVE: This retrospective, observational cohort study investigated whether the clinical features of a patient's pain, including anatomical location, organ system and likely treating speciality, impact on the delivery of analgesia within 30 min in EDs. METHODS: Data were obtained from 24 centres across Australia between April 2008 and March 2009. Principal outcome was delivery of analgesia within 30 min or less. Factors that might explain any differences were analysed, including anatomical location of the pain, likely treating speciality, organ system affected, age, sex, day and time of presentation, hospital location, documented pain score and triage category. Analysis was by the χ(2)-test for independence of proportions and multiple logistic regression. A P-value <0.05 was considered statistically significant. RESULTS: There were 4598 patients, of whom 2578 were male. The median age was 36 years (range 0-103). Both limb origin of pain (χ(2) = 46.1, P < 0.001) and documentation of a pain score (χ(2) = 48.6, P < 0.001) were strongly associated with delivery of analgesia within 30 min. Attending a rural ED was a significant risk factor for delayed analgesia (χ(2) = 12.5, P < 0.001). Burns patients (40.2%, 47 of 117, P < 0.001) and orthopaedic patients (26.1%, 259 of 992, P < 0.001) were much more likely to received analgesia within 30 min than the mean (19.5%, 896 of 4598). CONCLUSIONS: Patients presenting with burns, orthopaedic conditions or with a limb location of pain are more likely to receive analgesia within 30 min in Australian EDs. Clinicians should be aware of possible trends in the delivery of timely analgesia to patients with pain.

An Australian audit of ED pain management patterns.

INTRODUCTION: Timely and appropriate pain management is an important quality indicator of ED performance. Emergency health care workers are well positioned to become active leaders and innovatively responsive in reducing human suffering. A pain management audit was conducted to determine Australia practice patterns. METHODS: A 12-month retrospective descriptive cohort audit was undertaken. Through the randomization process a medical record audit tool was completed for each record identified. Ethical approval for the study was obtained. RESULTS: Seventy-four hospitals agreed to conduct the audit, 36 (48%) provided data. The total number of patient notes reviewed was 2,066. Ninety-five percent (1,966) of patients arrived by ambulance. Of the patients (n=547; 56.4%) with a documented triage pain score the majority arrived in severe pain (n=300; 41.3%). Of the total number of patients (1,966) documented arriving in pain 1,473 (74.9%) received an analgesic. Six hundred and forty-four (32.7%) patients received an opioid. From time of emergency department arrival, the median time for analgesic administration was 70 minutes (IQR 58 minutes to 92 minutes). Twenty-five emergency departments (69.4%) had pain management policies that enabled nurses to initiate a pharmacological analgesia without medical consultation. DISCUSSION: The Australian pain management audit highlighted current practices and potential areas for further research. While the audit demonstrated that nurse initiated pain management interventions promoted better analgesic response, greater consistency of triage pain assessment, code allocation, and documentation of pain scores may go some way to improving the timeliness of analgesia.

Identifying the opportunities for health promoting emergency departments.

STUDY OBJECTIVE: To describe the opportunities for health promotion in emergency departments (EDs). METHODS: A comprehensive literature review and consultation with ED staff (seven focus groups) and other health professionals (workshop). RESULTS: Opportunities for patient health information and education within EDs are described in the literature. In contrast, the health promoting hospitals literature showcases integrated approaches for health promotion, emphasizing organisational structures, and culture changes to support effective health promotion. This type of integration has not developed in EDs, where individual issues based health promotion projects have emerged. ED staff readily described the:existing health promotion interventions and possible improvements and opportunities for potential health promotion interventions related to the needs of their patients, the community or their organisation. Other health professionals supported EDs taking a greater role in health promotion and suggested organisational partnerships that would assist in developing this. CONCLUSION: There are numerous opportunities to enhance health promotion in EDs. With support, EDs could deliver comprehensive health promotion programs for patients, staff, and communities.