Pain Assessment in Pediatric Emergency Departments: A National Survey.

OBJECTIVE: Accurate and consistent assessment of pain is essential in the pediatric emergency setting. Despite recommendations for formal assessment protocols, current data are lacking on pain assessment in pediatric emergency departments (EDs) and, specifically, whether appropriate tools are being used for different age groups. Our aim was to determine the status of pain assessment in US pediatric EDs. METHODS: We disseminated an online cross-sectional survey (after piloting) to pediatric EDs within the Children's Hospital Association. Responses were analyzed for each question owing to incomplete responders. We report descriptive statistics, with categorical variables compared with χ2 (P < 0.05 considered statistically significant). RESULTS: From 120 pediatric EDs, we received 57 responses (48%). Most respondents (28/49, 57%) were from freestanding pediatric centers. All 57 EDs (100%) performed formal pain assessments, with 31 (63%) of 49 using an ED-specific protocol. Freestanding children's hospitals were more likely to have ED-specific protocols (21/31, 68%) than nonfreestanding (10/31, 32%) (P = 0.04). Among 56 responders, 100% stated that nurses are tasked with assessing pain. For children 0 to 2 years, 29 (54%) of 54 used the Face, Legs, Activity, Cry, Consolability scale. Numerical scales were increasingly used with older ages: 3 to 4 years, 40 (80%) of 50; 5 to 10 years, 49 (98%) of 50; and 11 to 21 years, 50 (100%) of 50. CONCLUSIONS: In contrast to prior research, US pediatric EDs are routinely assessing pain with scales that are mostly appropriate for their respective age groups. Further research is needed to explore barriers to implementing appropriate pain ratings for all children and, ultimately, how these assessments impact the care of children in the emergency setting.

Effectiveness of fever education in a pediatric emergency department.

OBJECTIVE: This study was designed to assess the impact of a brief educational video shown to parents during an emergency department visit for minor febrile illnesses. We hypothesized that a video about home management of fever would reduce medically unnecessary return emergency department visits for future febrile episodes. METHODS: A convenience sample of 280 caregivers presenting to one urban pediatric emergency department was enrolled in this prospective, randomized cohort study. All the caregivers presented with a child aged 3 to 36 months with complaint of fever and were independently triaged as nonemergent. A pretest and posttest were administered to assess baseline knowledge and attitudes about fever. One hundred forty subjects were randomized to view either an 11-minute video about home management of fever or a control video about child safety. Subjects were tracked prospectively, and all return visits for fever complaints were independently reviewed by 3 pediatric emergency physicians to determine medical necessity. RESULTS: There were no differences between the fever video and the control groups in baseline demographics (eg, demographically comparable). The fever video group had a significant improvement in several measures relating to knowledge and attitudes about childhood fever. There was no statistical difference between the intervention and control groups in subsequent return visits or in the determination of medical necessity. CONCLUSIONS: A brief standardized video about home management of fever improved caregiver knowledge of fever but did not decrease emergency department use or increase medical necessity for subsequent febrile episodes.

Tracheal intubation practice and maintaining skill competency: survey of pediatric emergency department medical directors.

PURPOSE: One of the most critical resuscitation skills in pediatric emergency medicine is establishing and maintaining a patent airway. This often requires tracheal intubation (TI). The purpose of this survey study was to determine the practice of TI in pediatric emergency departments (PEDs) and the methods used by PED medical directors to maintain TI competency among PED physicians. METHODS: This is an observational survey study. Medical directors of PEDs were surveyed through e-mail (http://web-online-surveys.com). There were 20 survey questions: 4 yes/no and 16 multiple choice. RESULTS: Of the 108 PED medical directors who were surveyed, 61 (57%) completed the questionnaire. The mean number of TI per PED for 1 year was 63.7; SD, 79.3; median, 37; range, 3 to 400. The mean percentage of TI that were rapid sequence intubations was 76%; SD, 19.8%; median, 83%; range, 30% to 100%. The physician types most commonly performing TI on nontrauma versus trauma patients were as follows: pediatric emergency medicine, 50 (82%) versus 43 (70%); emergency medicine, 4 (7%) versus 4 (7%); and anesthesiology, 1 (2%) versus 4 (7%). The physician types most commonly consulted for difficult airway patients were: anesthesiology, 40 (66%); and pediatric critical care, 14 (23%). Alternative or rescue airway equipment/procedures available to PED were as follows: laryngeal mask airway (LMA), 50 (90%); needle cricothyroidotomy, 47 (77%); fiberoptic scope, 34 (56%); and tracheal tube introducer, 22 (36%). There were 38 (62%) PED medical directors who judged the number of TI opportunities to be inadequate to maintain TI competency among their physicians. The following activities reported as required for remedial training or to maintain TI competency were: pediatric advanced life support/advanced pediatric life support courses, 42 (69%); simulation training, 29 (48%); perform TI under the supervision of an anesthesiologist, 23 (38%); advance airway course, 21 (34%); and/or none, 1 (2%). CONCLUSIONS: Most PED TI for both nontrauma and trauma patients were performed by PED physicians. Most of these were rapid sequence intubations. The number of TI per PED had a large range. Most PED medical directors judged this number to be inadequate to maintain TI competency. Didactic activities to maintain TI skills were most common, but many other activities were used.

Age limits and transition of health care in pediatric emergency medicine.

OBJECTIVE: To describe the practice reported by pediatric emergency department (PED) medical directors regarding age limits and transition of health care in their emergency departments and institutions. METHODS: A 28-question survey was sent by e-mail to 116 PED medical directors. Descriptive statistics were used to report results; chi tests were used for comparing categorical data. RESULTS: The survey was completed by 73 PED medical directors (63%). Age-limit policies were present in 58 (79%) of the PEDs, and 56 reported a specific age. The 18th and 21st birthdays were the most common specific ages cited. Thirty-six PEDs (64%) had an age limit of younger than 21 years. Pediatric emergency departments with age limits of 21 years or older versus younger than 21 years had a significantly higher rate of being associated with freestanding children's hospitals (P = 0.037). Appropriate exceptions to the age-limit policy included patients both over and under the age limit. The most common overage limit exception was cystic fibrosis, and the most common underage limit exception was teenage pregnancy. Thirteen PED medical directors (18%) were aware of a transition-of-care (pediatric to adult care provider) policy or work group at their institution, and 47 (64%) thought that such a work group would be valuable to addressing transition-of-care issues. CONCLUSION: In pediatric emergency medicine, the age of transition from pediatric to adult emergency care providers is variable both between and within institutions. Most PEDs have age limits of younger than 21 years. Most PED medical directors support a multidisciplinary work group or committee as a method of addressing transition of care. Known barriers to transition of care previously reported in the literature are reviewed.

Education of Out-of-Hospital Emergency Medical Personnel in Pediatrics: Report of a National Task Force.

The Pediatric Education Task Force has developed a list of major topics and skills for inclusion in pediatric curricula for EMS providers. Areas of controversy in the management of pediatric patients in the prehospital setting are outlined, and helpful learning tools are identified. [Gausche M, Henderson DB, Brownstein D, Foltin GL, for the Pediatric Education Task Force: Education of out-of-hospital emergency medical personnel in pediatrics: Report of a National Task Force. Ann Emerg Med January 1998;31:58-64.].