Dianne Crellin

Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting

Background:  Assessing procedural pain and distress in young children is difficult. A number of behavior‐based pain and distress scales exist which can be used in preverbal and early‐verbal children, and these are validated in particular settings and to variable degrees.

Does the standard intravenous solution of fentanyl (50 µg/mL) administered intranasally have analgesic efficacy?

Background:  Intranasal (IN) fentanyl provides rapid and powerful non‐parenteral analgesia in the ED. A concentrated solution of fentanyl (300 µg/mL) has been used in prior trials, yet many ED use the standard solution at a concentration of 50 µg/mL, which is widely available and of low cost. We set out to determine if this lower concentration of fentanyl is also efficacious.

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 (SpO2) 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 SpO2, 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.

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?

Abstract 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.

Factors influencing consistency of triage using the Australasian Triage Scale: Implications for guideline development

Objective:  To examine the influence of the nurse, the type of patient presentation and the level of hospital service on consistency of triage using the Australasian Triage Scale.

Does Nebulized Lidocaine Reduce the Pain and Distress of Nasogastric Tube Insertion in Young Children? A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVES. Nasogastric tube insertion is a common procedure in children that is very painful and distressing. Although nebulized lidocaine has been shown to be effective in reducing the pain and discomfort of nasogastric tube insertion in adults, there have been no similar studies in children. We set out to investigate the role of nebulized lidocaine in reducing pain and distress of nasogastric tube insertion in young children. METHODS. We conducted a randomized, double-blind, placebo-controlled trial of nebulized 2% lidocaine at 4 mg/kg versus saline placebo during nasogastric tube insertion at a tertiary urban pediatric emergency department. Patients were eligible if they were aged from 1 to 5 years with no comorbid disease and a clinical indication for a nasogastric tube. Nebulization occurred for 5 minutes, 5 minutes before nasogastric tube insertion. Video recordings before, during, and after the procedure were rated using the Face, Legs, Activity, Cry, and Consolability (FLACC) pain and distress assessment tool (primary outcome measure) and pain and distress visual analog scale scores (secondary outcome measures). Difficulty of insertion and adverse events were also assessed. RESULTS. Eighteen participants were nebulized with 2% lidocaine and 18 participants with normal saline. Nebulization was found to be highly distressing. FLACC scores during nasogastric tube insertion were very high in both groups. There was a trend in the post–nasogastric tube insertion period toward lower FLACC scores in the lidocaine group. Visual analog scale scores for this postinsertion period were significantly lower in the lidocaine arm for pain and distress. There were no significant differences between groups in terms of difficulty of insertion and the number of minor adverse events. The study was terminated early because of the distress and treatment delay associated with nebulization. CONCLUSIONS. Nasogastric tube insertion results in very high FLACC scores irrespective of lidocaine use. Nebulized lidocaine cannot be recommended as pain relief for nasogastric tube insertion in children. The delay and distress of nebulization likely outweigh a possible benefit in the postinsertion period.

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 childrens 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.

Procedural pain and distress in young children as perceived by medical and nursing staff

Introduction:  Currently there is no comparison of pain and distress experienced by young children undergoing a range of procedures. This would be important when considering choices between alternative management approaches and to facilitate development of measures to reduce procedural pain and distress. We set out to determine staff perceptions of pain and distress across a range of common emergency procedures.

Poor agreement in application of the Australasian Triage Scale to paediatric emergency department presentations

Background. The Australasian Triage Scale (ATS) is used in Australian emergency departments (ED) to describe patient priority on arrival. This study aimed to determine the level of inter-rater consistency with which the scale is applied to paediatric presentations. Additionally, it sought to document the level of certainty with which nurses apply the scale. Method: An anonymous survey of emergency nurses responsible for paediatric triage decisions using written patient profiles. Results. The level of agreement between nurses applying the ATS to paediatric presentations can be described as poor and appears lower than the consistency with which it is applied to adult presentations. Conclusion. Inconsistent allocation of ATS category implies variable patient waiting times, which may have detrimental effects on patient condition. Hence, efforts must be made to address the inconsistency that exists in paediatric triage decisionmaking.

Who is responsible for pediatric triage decisions in Australian emergency departments: A description of the educational and experiential preparation of general and pediatric emergency nurses

Background Pediatric presentations to the emergency department (ED) account for approximately one third of ED presentations. Triage is the process employed by the ED to prioritize presenting patients, including children, on the basis of clinical urgency. This role is undertaken by emergency nurses, and a range of recommendations are available regarding the level of experience and education required by the nurse responsible for pediatric triage decisions. However, little is known about the actual education and experience of nurses undertaking pediatric triage. Objectives To describe the level of experiential and educational preparation of emergency nurses responsible for pediatric triage decisions in pediatric and adult and pediatric population EDs. Methods An anonymous survey of emergency nurses responsible for pediatric triage decisions in a number of specialist and mixed EDs was conducted. Results Education and experience varies widely among nurses responsible for pediatric triage decisions. Many nurses practicing pediatric triage do not meet recognized guidelines for the levels of education and experience required to undertake pediatric triage. Nurses practicing in mixed population EDs were less likely to meet the recommended educational requirements than pediatric emergency nurses and yet reported no difference in their level of confidence in undertaking pediatric triage. Conclusions Educationalists and managers must make a commitment to pediatric triage preparation for nurses in EDs providing pediatric services. In particular, emphasis must be placed on providing pediatric continuing education for nurses practicing in mixed population EDs. However, it is also essential that the impact of education and experience on patient outcomes be investigated before an attempt is made to influence the preparation of nurses for triage.