Improving paediatric pain management in the emergency department: An integrative literature review.

Background: Children presenting to the emergency department continue to experience suboptimal pain management. While evidence-based pain management interventions are available to clinicians, effective and sustainable practice change is yet to be achieved. This practice gap requires a collaborative approach to knowledge translation targeting systems of care.

Objectives: The purpose of this review was to explore systems level change in the emergency department for improved paediatric pain management.

Design: Integrative review.

Data Sources: CINAHL, Embase, PubMed/Medline, Dynamed, Cochrane, Scopus, Prospero and Joanna Briggs Institute were systematically searched, and clinical guidelines and reference lists scanned.

Review Methods: Studies were screened and selected according to the inclusion criteria, and independently appraised for risk of bias. Integrative review methodology informed data extraction and synthesis, focused on organisational context and engagement, facilitation and implementation of practice change, key components of the pain management interventions, and evaluation.

Results: Twenty studies met the inclusion criteria: 18 uncontrolled pretest-posttest and two pseudo-randomised design. Study populations ranged from children with a specific presentation, to all presenting children. All studies adopted a multifaceted approach to organisational change, bundling various interventions including pain assessment tools and management protocols, clinician education, nurse-initiated analgesia, feedback and family engagement. Four studies used local systems analysis to inform interventions and two studies applied an implementation framework. Time to analgesia was the most commonly improved primary outcome. Parent and child sensitive outcomes were assessed in five studies. Interventions that hold the most promise for optimised pain management if embedded in the workplace include nurse-initiated analgesia and family involvement at each stage of pain management in the emergency department.

Conclusion: The way forward is to respectfully engage all stakeholders-children, parents and clinicians-to collaboratively develop evidence-based, sustainable solutions aligned with the emergency department context. Guided by an implementation framework, future research designed to creatively translate evidence into practice and facilitate change at a systems level is a priority. Key to this solution is the integration of family involvement in pain management, considering child and family sensitive outcome measures. Effectiveness of new interventions should be evaluated in the short and long term to embed sustainable practice change. Frontline nurses are well placed to lead this transformation in paediatric pain management in the emergency department.