An Australian survey of health professionals' perceptions of use and usefulness of electronic medical records in hospitalised children's pain care.

Pain in hospitalised children is common, yet inadequately treated. Electronic medical records (EMRs) can improve care quality and outcomes during hospitalisation. Little is known about how clinicians use EMRs in caring for children with pain. This national cross-sectional survey examined the perceptions of clinician-EMR users about current and potential use of EMRs in children's pain care. One hundred and ninety-four clinicians responded (n = 81, 74% nurses; n = 21, 19% doctors; n = 7, 6% other); most used Epic (n = 53/109, 49%) or Cerner (n = 42/109, 38%). Most (n = 84/113, 74%) agreed EMRs supported their initiation of pharmacological pain interventions. Fewer agreed EMRs supported initiation of physical (n = 49/113, 43%) or psychological interventions (n = 41/111, 37%). Forty-four percent reported their EMR had prompt reminders for pain care. Prompts were perceived as useful (n = 40/51, 78%). Most agreed EMRs supported pain care provision (n = 94/110, 85%) and documentation (n = 99/111, 89%). Only 39% (n = 40/102) agreed EMRs improved pain treatment, and 31% (n = 32/103) agreed EMRs improved how they involve children and families in pain care. Findings provide recommendations for EMR designs that support clinicians' understanding of the multidimensionality of children's pain and drive comprehensive assessments and treatments. This contribution will inform future translational research on harnessing technology to support child and family partnerships in care.

Barriers and co-designed strategies for the implementation of negative pressure wound therapy in acute pediatric burn care in Australia: A mixed method study.

PURPOSE: Pediatric burn injuries are a global clinical issue causing significant morbidity. Early adjunctive negative pressure wound therapy improves re-epithelialization rates in children with burns, yet adoption in acute burn care is inconsistent. This investigation aimed to determine barriers to the implementation of adjunctive negative pressure wound therapy for the acute management of pediatric burns and co-design targeted implementation strategies. METHODS: A sequential mixed methods design was used explore barriers to adjunctive negative pressure wound therapy implementation in acute pediatric burn care. An online questionnaire was disseminated to healthcare professionals within four major Australian pediatric hospitals, each with a dedicated burns service. Barriers were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews with senior clinicians tailored implementation strategies to local contexts. A stakeholder consensus meeting consolidated implementation strategies and local processes. RESULTS: Sixty-three healthcare professionals participated in the questionnaire, and semi-structured interviews involved nine senior burn clinicians. We identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change, patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies, intervention complexity, and poor implementation planning. CONCLUSION: Multiple contextual factors affect negative pressure wound therapy uptake in acute pediatric burn settings. Results will inform a multi-state stepped-wedge cluster randomized controlled trial. Additional resources, education, training, updated policies, and guidelines are required for successful implementation. It is anticipated that adjunctive negative pressure wound therapy, in conjunction with tailored implementation strategies, will enhance adoption and sustainability. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12622000166774. Registered 1 February 2022.

"Seeing the light in the shade of it": primary caregiver and youth perspectives on using an inpatient portal for pain care during hospitalization.

ABSTRACT: Studies from multiple countries report that most hospitalized children, especially the youngest and sickest, experience pain that is often severe yet inadequately treated. Evidence suggests this can lead to immediate and lifelong consequences affecting children, families, and communities. Partnership and shared decision-making by children, families, and clinicians is the ideal pediatric healthcare model and can improve care quality and safety, including pain care. A growing evidence base demonstrates that inpatient portals (electronic personal health record applications linked to hospital electronic medical or health records) can improve child and family engagement, outcomes, and satisfaction during hospitalization. This study examined the perspectives of caregivers of hospitalized children and of hospitalized youth about using an inpatient portal to support their engagement in pain care while in hospital. A qualitative descriptive study design was used and 20 participants (15 caregivers and 5 youth) with various painful conditions in one pediatric hospital participated in semistructured interviews. The authors applied a reflexive content analysis to the data and developed 3 broad categories: (1) connecting and sharing knowledge about pain, (2) user-centred designs, and (3) preserving roles. These findings outlined caregiver and youth recommendations for portal configurations that deeply engage and empower children and families in pain care through multidirectional knowledge sharing, supporting caregiver and clinicians' roles without burdening, or replacing human interaction implicit in family-centered pain care. Further research should measure the impact of portals on pain-related outcomes and explore the perspectives of clinicians.

Call to focus on digital health technologies in hospitalized children's pain care: clinician experts' qualitative insights on optimizing electronic medical records to improve care.

ABSTRACT: Most hospitalized children experience pain that is often inadequately assessed and undertreated. Exposure to undertreated childhood pain is associated with negative short-term and long-term outcomes and can detrimentally affect families, health services, and communities. Adopting electronic medical records (EMRs) in pediatric hospitals is a promising mechanism to transform care. As part of a larger program of research, this study examined the perspectives of pediatric clinical pain experts about how to capitalize on EMR designs to drive optimal family-centered pain care. A qualitative descriptive study design was used and 14 nursing and medical experts from 5 countries (United States, Canada, United Kingdom, Australia, and Qatar) were interviewed online using Zoom for Healthcare. We applied a reflexive content analysis to the data and constructed 4 broad categories: "capturing the pain story," "working with user-friendly systems," "patient and family engagement and shared decision making," and "augmenting pain knowledge and awareness." These findings outline expert recommendations for EMR designs that facilitate broad biopsychosocial pain assessments and multimodal treatments, and customized functionality that safeguards high-risk practices without overwhelming clinicians. Future research should study the use of patient-controlled and family-controlled interactive bedside technology to and their potential to promote shared decision making and optimize pain care outcomes.

Behavioural drivers influencing emergency department attendance in Victoria during the 2020 COVID-19 pandemic: A mixed methods investigation.

OBJECTIVE: To identify behavioural drivers and barriers that may have contributed to changes in ED attendance during the first 10 months of the coronavirus disease 2019 (COVID-19) pandemic in Victoria. METHODS: We conducted a mixed methods analysis of patients who attended one of eight participating EDs between 1 November 2019 and 31 December 2020. A random sample of patients were chosen after their visit and invited to participate in an online survey assessing behavioural drivers and barriers to attendance. The study timespan was divided into four periods based on local and world events to assess changes in attitudes and behaviours over this period. RESULTS: A total of 5600 patients were invited to complete the survey and 606 (11%) submitted sufficient information for analysis. There were significant differences in participants' attitudes towards healthcare and EDs, levels of concern about contracting and spreading COVID-19 and the influence of mask wearing. Patients expressed more concern about the safety of an ED during the largest outbreak of COVID-19 infections than they did pre-COVID, but this difference was not sustained once community infection numbers dropped. General concerns about hospital attendance were higher after COVID than they were pre-COVID. A total of 27% of patients specifically stated that they had delayed their ED attendance. CONCLUSION: Patients expressed increased concerns around attending ED during the first 10 months of the 2020 COVID-19 pandemic and frequently cited COVID-19 as a reason for delaying their presentation. These factors would be amenable to mitigation via focussed public health messaging.

Comparison of the Psychometric Properties of the FLACC Scale, the MBPS and the Observer Applied Visual Analogue Scale Used to Assess Procedural Pain.

PURPOSE: The purpose of this study was to compare the psychometric data and feasibility and clinical utility of the Face Legs, Activity, Cry and Consolability scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs) used to assess procedural pain in infants and young children. PATIENTS AND METHODS: Twenty-six clinicians assessed videorecorded segments of 100 infants and young children who underwent a painful and/or distressing procedure in the emergency department using the FLACC scale, the MBPS and the VASobs pain and VASobs distress. RESULTS: VASobs pain scores were lowest across all procedures and phases of procedures (p < 0.001). Inter-rater reliability was lowest for VASobs pain scores (ICC 0.55). Sensitivity and specificity were highest for FLACC scores (94.9% and 72.5%, respectively) at the lowest cut-off score (pain score two). Observers changed their MBPS scores more often than they changed FLACC or VASobs scores, but FLACC scores were more often incomplete. Reviewers did not consider any scale of use for procedural pain measurement. CONCLUSION: The reliability and sensitivity of the FLACC and MBPS were supported by study data but concerns about the capacity of these scales to distinguish between pain- and non-pain-related distress were raised. The VASobs cannot be recommended. Despite its limitations, the FLACC scale may be better suited than other scales for procedural pain measurement.

The Psychometric Properties of the Visual Analogue Scale Applied by an Observer to Assess Procedural Pain in Infants and Young Children: An Observational Study.

PURPOSE: The Visual Analogue Scale applied by an observer (VASobs) is widely used to quantify pain but the evidence to support validity is poor. The aim of this study was to evaluate the psychometric and practical properties of the VASobs used to assess procedural pain in infants and young children. DESIGN AND METHODS: In an observational study, 26 clinicians applied the VASobs independently to video segments of 100 children aged six to 42 months undergoing a procedure to generate pain and distress scores. Each video segment was scored by four randomly selected reviewers. RESULTS: Reliability for pain scores was poor to fair (ICC 0.35 to 0.55) but higher for distress scores (ICC 0.6 to 0.89). At a cut-off score of 3, sensitivity and specificity were 84.7% and 95.0%, respectively for pain and 91.5% and 77.5% respectively for distress. Linear mixed modelling confirmed responsiveness. An increase in pain scores (regression slope 4.95) and distress scores (regression slope 5.52) across phases (baseline to procedure) was seen for painful procedures. The correlation between VASobs pain and FLACC scores was good (r = 0.74) and correlations between VASobs distress and FLACC scores were excellent (r = 0.89). CONCLUSION: VASobs was easily applied and preferred by clinicians. Despite evidence of sensitivity and responsiveness to pain, the reliability results were poor, and this scale cannot be recommended for use. PRACTICE IMPLICATIONS: The results of this study prevent recommending the VASobs for assessing procedural pain in infants and young children for clinical or research purposes.

A Systematic Review of the Psychometric Properties of the Modified Behavioral Pain Scale (MBPS).

PROBLEM: Clinicians and researchers require a valid way to assess procedural pain experienced by infants and children. The Modified Behavioral Pain Scale (MBPS) has been used to assess immunisation pain. However, it is unknown whether it is valid for this purpose and whether use can be extended to other procedures. The aim of this study was to rigorously assess evidence addressing the psychometric properties of this scale and to provide recommendations for its use. ELIGIBILITY CRITERIA: Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the MBPS applied to children (birth to 18years) and randomised controlled trials (RCT) using the MBPS were included. SAMPLE: Twenty-eight studies (8 psychometric and 20 RCTs) were included. RESULTS: Studies were of varying quality. Sufficient data was available to cautiously accept the MBPS as valid for assessing immunisation related pain in infants aged 2 to 22months. There was insufficient data to support the psychometrics in other age groups or in circumstances other than immunisation. There is no data addressing the clinical utility of the MBPS. CONCLUSIONS: It is not possible at this time to confidently accept the MBPS as suitable for assessing all procedural pain in young children. IMPLICATIONS: Studies to evaluate the capacity of the MBPS to assess pain in a range of procedures and to distinguish between pain and non-pain related distress are needed if it is to be recommended.

The Psychometric Properties of the FLACC Scale Used to Assess Procedural Pain.

The Face, Legs, Activity, Cry, and Consolability (FLACC) scale is one of the most commonly and widely used behavioral observation pain scales. The aim of this study was to test the psychometric and practical properties of the FLACC scale to quantify procedural pain in infants and young children. Twenty-six clinicians independently applied the FLACC scale to segments of video collected from 100 children aged 6 to 42 months undergoing a procedure. Video segments were scored by 4 reviewers. Inter- and intrarater reliability coefficients were high (.92 and .87, respectively). Linear mixed modeling confirmed scale responsiveness (differences in difference between FLACC scores across phases for painful versus nonpainful procedures was 4.2, 95% confidence interval = 3.67-4.81). Sensitivity and specificity were 94.9% and 73.5%, respectively, at a cutoff of 2. However, the mean difference across phases for children with baseline scores >3 was much lower than for children with scores <3, P = .0001. Correlations between FLACC and Visual Analog Scale observer pain and distress were good (r = .74 and r = .89, respectively). This study supports the reliability and sensitivity of the FLACC scale for procedural pain assessment. However, the circumstances of procedures interfered with application of the scale and the findings question the capacity of the scale to differentiate between pain- and nonpain-related distress. PERSPECTIVE: This article provides evidence that the FLACC scale is reliable and sensitive to pain for procedural pain assessment. Concerns remain about specificity and scale design. Identification of a scale valid for this purpose is needed to provide a platform for improved procedural pain management in infants and young children.

The Psychometric Properties of the MBPS Scale Used to Assess Procedural Pain.

The Modified Behavioral Pain Scale (MBPS) was designed to assess procedural pain in infants and is considered valid for assessing immunization pain. The aim of this study was to assess the practical and psychometric properties of the MBPS when applied to other commonly performed procedures. Twenty-six clinicians independently applied the MBPS scale to segments of video collected from 100 infants and children aged 6 to 42 months undergoing 1 of 4 procedures in the emergency department. Positive correlation between MBPS and Visual Analogue Scale observer applied (VASobs) pain (r = .74) was shown and inter- and intrarater reliability coefficients were high (.87 and .89, respectively). Construct validity was shown by scale responsiveness to painful stimuli (4.6 times increase in scores across phases) and the capacity of the scale to distinguish between painful versus nonpainful procedures (P < .001). However, mean baseline scores for procedures were not 0 (likely a function of item descriptors for a "0" score) and the mean difference increased across phases for children with baseline scores >3, which was much lower than for children with scores <3 (P = .0001). Finally, 28% of scores changed after the second viewing of a video segment. The MBPS appears reliable and sensitive to procedural pain when applied by clinicians. Results question the capacity of the scale to differentiate between pain- and nonpain-related distress, the feasibility of this scale, and the appropriateness of item descriptors for medical procedures. PERSPECTIVE: This article presents the psychometric and practical properties of the MBPS applied to assess procedural pain. Identification of a suitable scale for this purpose will support improved pain management in infants and young children who undergo painful procedures.

Procedural Pain Scale Evaluation (PROPoSE) study: protocol for an evaluation of the psychometric properties of behavioural pain scales for the assessment of procedural pain in infants and children aged 6-42 months.

INTRODUCTION: Infants and children are frequently exposed to painful medical procedures such as immunisation, blood sampling and intravenous access. Over 40 scales for pain assessment are available, many designed for neonatal or postoperative pain. What is not well understood is how well these scales perform when used to assess procedural pain in infants and children. AIM: The aim of this study was to test the psychometric and practical properties of the Face, Legs, Activity, Cry and Consolability (FLACC) scale, the Modified Behavioural Pain Scale (MBPS) and the Visual Analogue Scale (VAS) observer pain scale to quantify procedural pain intensity in infants and children aged from 6-42 months to determine their suitability for clinical and research purposes. METHODS AND ANALYSIS: A prospective observational non-interventional study conducted at a single centre. The psychometric and practical performance of the FLACC scale, MBPS and the VAS observer pain scale and VAS observer distress scale used to assess children experiencing procedural pain will be assessed. Infants and young children aged 6-42 months undergoing one of four painful and/or distressing procedures were recruited and the procedure digitally video recorded. Clinicians and psychologists will be recruited to independently apply the scales to these video recordings to establish intrarater and inter-rater reliability, convergent validity responsiveness and specificity. Pain score distributions will be presented descriptively; reliability will be assessed using the intraclass correlation coefficient and Bland-Altman plots. Spearman correlations will be used to assess convergence and linear mixed modelling to explore the responsiveness of the scales to pain and their capacity to distinguish between pain and distress. ETHICS AND DISSEMINATION: Ethical approval was provided by the Royal Children's Hospital Human Research Ethics Committee, approval number 35220B. The findings of this study will be disseminated via peer-reviewed journals and presented at international conferences.

Systematic review of the Face, Legs, Activity, Cry and Consolability scale for assessing pain in infants and children: is it reliable, valid, and feasible for use?

The Face, Legs, Activity, Cry and Consolability (FLACC) scale is one of the most widely used behavioural observation pain scales. However, the psychometrics of the scale have not been adequately summarised and evaluated to provide clear recommendations regarding its use. The aim of this study was to rigorously evaluate the reliability, validity, feasibility, and utility of the scale for clinical and research purposes and provide recommendations regarding appropriate use of the scale. Databases searched were MEDLINE, CINAHL, Embase, PsycINFO (using the Ovid, PubMed, and Ebscohost platforms), The Cochrane Database of Systematic reviews and Cochrane Controlled Trials, and Google Scholar. Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the FLACC scale applied to children (birth to 18 years) and randomised controlled trials (RCT) using the FLACC scale to measure a study outcome in infants and children. Data extraction included study design, population demographics, and psychometric data. Analysis involved in this study are quality assessment of the psychometric evaluation studies and the RCTs using the COSMIN checklist and the Jadad scale, respectively, and narrative synthesis of all results. Twenty-five psychometric evaluations studies and 52 RCTs were included. The study population, circumstances, and quality of the studies varied greatly. Sufficient data addressing postoperative pain assessment in infants and children exist. Some positive data support the psychometrics of the scale used to assess postoperative pain in children with cognitive impairment. Limited and conflicting data addressing procedural pain assessment exist. Content validity and scale feasibility have had limited psychometric evaluation. There are insufficient data to support the FLACC scale for use in all circumstances and populations to which is currently applied.

Can simple mobile phone applications provide reliable counts of respiratory rates in sick infants and children? An initial evaluation of three new applications.

BACKGROUND: Respiratory rate is an important sign that is commonly either not recorded or recorded incorrectly. Mobile phone ownership is increasing even in resource-poor settings. Phone applications may improve the accuracy and ease of counting of respiratory rates. OBJECTIVES: The study assessed the reliability and initial users' impressions of four mobile phone respiratory timer approaches, compared to a 60-second count by the same participants. METHODS: Three mobile applications (applying four different counting approaches plus a standard 60-second count) were created using the Java Mobile Edition and tested on Nokia C1-01 phones. Apart from the 60-second timer application, the others included a counter based on the time for ten breaths, and three based on the time interval between breaths ('Once-per-Breath', in which the user presses for each breath and the application calculates the rate after 10 or 20 breaths, or after 60s). Nursing and physiotherapy students used the applications to count respiratory rates in a set of brief video recordings of children with different respiratory illnesses. Limits of agreement (compared to the same participant's standard 60-second count), intra-class correlation coefficients and standard errors of measurement were calculated to compare the reliability of the four approaches, and a usability questionnaire was completed by the participants. RESULTS: There was considerable variation in the counts, with large components of the variation related to the participants and the videos, as well as the methods. None of the methods was entirely reliable, with no limits of agreement better than -10 to +9 breaths/min. Some of the methods were superior to the others, with ICCs from 0.24 to 0.92. By ICC the Once-per-Breath 60-second count and the Once-per-Breath 20-breath count were the most consistent, better even than the 60-second count by the participants. The 10-breath approaches performed least well. Users' initial impressions were positive, with little difference between the applications found. CONCLUSIONS: This study provides evidence that applications running on simple phones can be used to count respiratory rates in children. The Once-per-Breath methods are the most reliable, outperforming the 60-second count. For children with raised respiratory rates the 20-breath version of the Once-per-Breath method is faster, so it is a more suitable option where health workers are under time pressure.

The use of the faces, legs, activity, cry and consolability scale to assess procedural pain and distress in young children.

INTRODUCTION: Young children frequently undergo diagnostic and therapeutic procedures in the emergency department (ED). Although developed and validated for postoperative pain, Face, Legs, Activity, Cry, Consolability (FLACC) behavioral pain scores have been recommended and used for the assessment of procedural pain as well. We set out to assess if FLACC scores can differentiate pain and distress and establish a hierarchy of FLACC scores experienced during common ED procedures. METHODS: Prospective observational study at an urban tertiary children's hospital ED. We aimed to recruit 30 children each aged 6 to 42 months undergoing intravenous cannula (IV) insertion, nasogastric tube (NGT) insertion, metered dose inhaler (MDI) use and oxygen saturation (SpO(2)) measurement. Based on videotapes, 2 independent observers assessed pain and distress using FLACC scores during all procedural phases. RESULTS: A total of 125 patients were recruited and filmed for IV (33), NGT (30), MDI (34), and SpO2 (28). Median FLACC scores were as follows: NGT, 10 (interquartile range [IQR] 8.75-10); IV, 6.5 (IQR, 4.5-9.75); MDI, 6.5 (IQR, 0-9); and SpO(2), 0 (IQR, 0-0.5). The FLACC scores increased during each of the 3 phases, before the procedure, during restraint, and during the procedure. Procedural distress decreased with age except for NGT insertions, which remained very high irrespective of age. CONCLUSIONS: FLACC scores can be high during nonpainful procedures and the during restraint phase of painful procedures. This indicates that FLACC measures a composite of pain and distress in young children. This study identified substantial levels of pain and distress in young children by FLACC during commonly performed ED procedures, with nasogastric tube insertion having very high and intravenous cannulation/venepuncture and MDI having high FLACC scores.

National nursing registration in Australia: a way forward for nurse practitioner endorsement.

PURPOSE: The move to national registration of health professionals and the creation of the Nursing and Midwifery Board of Australia (NMBA) provides both challenges and opportunities for the regulation of nurse practitioners (NPs) in Australia. DATA SOURCES: National and state health policy documents, accessible on the Internet, concerning the regulation and endorsement processes for NPs in Australia were examined. CONCLUSIONS: The similarities between two of the previous jurisdictional NP endorsement processes in New South Wales and Victoria provide a common ground on which to build a robust national system. However, there are also key differences between these two states. These differences were mainly in the evidence required to assess competency of NP applicants and the authority to prescribe medications. All Victorian NP applicants were required to complete an approved medication subject at a master's level. IMPLICATIONS FOR PRACTICE: A consistent endorsement process that delivers NPs of the highest standard and allows for efficient use of their skills and expertise is vital. This needs to be performed with the aim of providing high-quality care in a regulatory environment that protects the public and clearly articulates the level of competence expected of all NPs.

Procedural restraint use in preverbal and early-verbal children.

BACKGROUND: Children frequently undergo diagnostic and therapeutic procedures while in hospital. To conduct these procedures safely, preverbal and early-verbal children in particular are often restrained. However, the literature on procedural restraint use is very limited. We set out to describe the extent of restraint use in 4 common procedures. METHODS: In this prospective observational study at an urban tertiary children's hospital emergency department, children aged 6 to 42 months undergoing 4 commonly performed procedures (intravenous insertion [IV], nasogastric tube [NGT] insertion, metered-dose inhaler [MDI] use, and oxygen saturation [O2 sat] measurement) were recruited. An independent observer assessed the extent and forcefulness of restraint use. Results were analyzed descriptively by age and procedure. RESULTS: One hundred twenty-four patients were recruited. All successful procedures (n = 123) were completed in 3 or fewer attempts, with 102 (82%) successful on the first attempt. Physical restraint was used in 89 (72%) of 124 patients overall. All patients undergoing IV (n = 33) and NGT insertion (n = 30), 64% of children requiring MDI (21/33), and only 18% of children requiring O2 sat measurements (5/28) were restrained. Twenty-three (79%) of the NGT insertions and 16 (48%) of IV insertions required moderate or forceful restraint. No or gentle restraint was used for 24 (73%) of MDI use and 100% of saturation measurements. Overall, 41 (87%) of 47 children 6 to 18 months old required restraint use as compared with 28 (68%) of 41 of 18- to 30-month-olds and 20 (57%) of 35 of 30- to 42-month-olds. CONCLUSIONS: Procedural restraint use in preverbal and early-verbal children is extensive, and significant amounts of force are used, which vary by procedure. Restraint use diminishes with age. A scoring system for restraint use is suggested based on the number of body parts restrained.