Objective. To compare the use of analgesia in children to adults in 3 different emergency department (ED) settings.
Methods. Forty adult and 40 pediatric ED charts were randomly selected for review at each of 3 institutions: an academic medical center with separate pediatric and adult EDs (SEP ED), a community academic medical center with a combined adult and pediatric ED (COMB ED), and a community hospital with a combined ED (COMTY ED). All patients presenting to the EDs from July 1993 to June 1994 within 12 hours of an isolated long bone fracture were eligible for inclusion. Data were collected on demographics, training of providers, analgesic use and dosing in the ED and on discharge, and time from triage to analgesic use.
Results. The mean pediatric and adult ages were 8.7 and 38.3 years, respectively. Overall, 152/240 (63%) patients received some form of analgesia in the ED, with the COMTY ED (41/80; 51%) offering significantly less analgesia than the COMB ED (58/80; 73%), but not the SEP ED (53/80; 66%). Pediatric patients (64/120; 53%) received significantly less analgesia in the ED than adult patients (88/120; 73%). This difference was significant at the COMB ED (pediatric 23/40; 58% vs adult 35/40; 88%) and COMTY ED (pediatric 15/40; 38% vs adult 26/40; 65%), but not at the SEP ED (pediatric 26/40; 65% vs adult 27/40; 68%). 195/240 (81%) patients received discharge pain medication. There were no differences between pediatric (93/120; 78%) and adult (102/120; 85%) discharge analgesic prescribing practices. Although there was no difference in appropriateness of analgesic doses in the ED, pediatric patients (20/74; 27%) were more likely than adult patients (3/88; 3%) to receive inadequate doses of analgesics on discharge from the ED.
Conclusions. ED analgesia continues to be used less frequently in the pediatric compared with the adult population. Inadequate dosing of discharge analgesic medication in children is a significant problem. Patterns of analgesic utilization may differ in different types of ED settings.
Controversy continues to surround the management of pain in the emergency department. Although it appears that the pediatric patient in the in-patient setting may be at particular risk for treatment with insufficient analgesia,1-4 little has been written about this difference in the emergency department. In 1990, Selbst and Clark5 found that in the emergency department setting, 60% of adult patients but only 28% of pediatric patients received adequate analgesia.
We conducted this study to explore current differences between adult and pediatric analgesic utilization in the emergency department. In addition, we wanted to examine differences in use between different types of emergency department settings. Finally, with a significant proliferation of literature related to methods of pain control and analgesia in the emergency department over the past 5 years, we wanted to determine whether a change in the use of analgesia has occurred.
Forty adult and 40 pediatric ED charts were randomly selected for review at each of 3 institutions: an academic medical center with separate pediatric and adult EDs (SEP ED), a community academic medical center with a combined adult and pediatric ED (COMB ED), and a community hospital with a combined ED (COMTY ED) (Table1). All patients presenting to the ED from July 1993 to June 1994 within 12 hours of an isolated long bone fracture were eligible for inclusion. Patients admitted or transferred from another institution, and those with altered mental status, treatment with an analgesic within 4 hours, or an isolated buckle fracture were excluded. Data were collected on demographics, training of those providing care, analgesic and sedative use and dosing in the ED, analgesic medication and dosing for discharge, and time from triage until analgesic use. Patients were categorized as pediatric (0 to 15 years) or adult (16 to 65 years) at each institution.
Adequacy of analgesic dosing was determined a priori using minimal adequate doses in Table 2. These doses were developed based on data from the Agency for Health Care Policy and Research guidelines on acute pain management6 or information from the pharmaceutical manufacturer. Where discrepancies were found, more conservative (lower) minimal adequate doses were used.
A power analysis was performed based on previous work5which demonstrated a 60% rate of adult ED analgesic administration versus a 28% rate in a pediatric group. Using an α of .05 and power of .8, it was estimated that 40 patients would be needed in each group. Categorical data were analyzed using χ2, continuous data using Student's t test, and proportions compared using a test of proportions. A P value ≤.05 was considered significant, and Bonferroni's method was used to correct for multiple comparisons.
A total of 120 pediatric and 120 adult charts were analyzed. The mean pediatric age was 8.7 ± 4.1 years and the mean adult age was 38.3 ± 13.9 years (Table 3). Although there were significantly more white patients seen at the COMTY ED and COMB ED, there were no differences in gender or race between the pediatric and adult groups. There was no difference in the procedure performed in the ED, with 71 (59%) pediatric fractures and 86 (72%) adult fractures splinted and 45 (38%) pediatric and 32 (27%) adult fractures reduced in the ED.
Overall, 152/240 (63%) patients received some form of analgesia in the ED, with the COMTY ED (41/80; 51%) offering significantly less analgesia than the COMB ED (58/80; 73%) (P < .007), but not the SEP ED (53/80; 66%) (P = .05) (Fig 1). Pediatric patients (64/120; 53%) received significantly less analgesia in the ED than adult patients (88/120; 73%) (P < .002). This difference was significant at the COMB ED (pediatric 23/40; 58% vs adult 35/40; 88%) (P < .003) and COMTY ED (pediatric 15/40; 38% vs adult 26/40; 65%) (P < .02), but not at the SEP ED (pediatric 26/40; 65% vs adult 27/40; 68%). Whereas there was no difference in the frequency of ED analgesic use in adults between the 3 ED settings, children at the COMTY ED (15/40; 38%) were less likely to receive analgesia than those at the SEP ED (26/40; 65%) (P < .014), but not the COMB ED (23/40; 58%) (P < .08). In addition, while there was no difference in the provision of narcotics, acetaminophen, or the use of hematoma blocks between pediatric and adult patients, the latter received more nonsteroidal anti-inflammatory agents (43/120; 36% vs 11/120; 9%) (P < .001) (Table4). Appropriateness of ED drug dosing was similar in the adult (70/84; 83%) and pediatric (54/61; 89%) groups.
The providers supplying direct patient care in the ED were at various training levels, with more pediatric (56/118; 47%) than adult (22/118; 19%) patients seen by residents (P < .001). For patient charts with signatures by both a resident and attending, analgesic use was assumed to be controlled by the resident. More adult (31/118; 26%) than pediatric (14/118; 12%) patients were seen by mid-level providers (pediatric nurse practitioners or physician assistants) (P < .001). There were significant differences in the level of provider training by site (Table 1). However, when analyzed by the categories resident, fellow, attending, or mid-level provider, there was no difference between providers with respect to the provision of analgesia in the ED. Also, there was no statistically significant difference in the provision of analgesia by attendings who were regular providers of care in the ED (103/156; 66%) versus moonlighters (14/26; 54%).
The mean time from triage to the provision of analgesia was 1.6 hours in the adult group and 1.4 hours in the pediatric group (P = ns). However, the time to analgesia was significantly shorter in the COMTY ED (0.8 hours) than in either the COMB ED or SEP ED (both 1.8 hours; P < .005).
The ratio of patients receiving discharge pain medication was 195/248 (81%) (Fig 2). Overall, there were no differences in the provision of discharge analgesic medication to pediatric (93/120; 78%) and adult (102/120; 85%) patients. There were no differences in the frequency of discharge analgesia in adults between the 3 ED settings. However, pediatric patients at the COMTY ED (25/40; 63%) were less likely to receive discharge analgesia when compared with the COMB ED (36/40; 90%) (P < .005), but not the SEP ED (32/40; 80%) (P = .08). Pediatric patients (51/120; 43%) were less likely to receive discharge narcotic analgesia than adults (77/120; 64%) (P < .002) (Table5). While there was no difference in appropriateness of analgesic doses given in the ED, pediatric patients (20/74; 27%) were more likely than adult patients (3/88; 3%) to receive inadequate doses of analgesics on discharge from the ED (P < .001). When examined by type of setting, this difference persisted at both the SEP ED (P< .002) and the COMB ED (P < .014).
The lack of adequate pain control has been raised as a significant concern in the medical community for many years. In addition, it appears that historically children have received relatively poorer pain control than the adult population.1,3,4 More recently, there has been significant interest in exploring alternative methods for providing analgesia for acutely painful conditions in the emergency setting.
Previous retrospective studies of ED analgesic use showed overall utilization rates of 30% to 40%.5,7 Thus, the overall rate of 63% in this study appears to represent a significant increase. It appears, however, that pediatric analgesic use remains significantly less than that for adults. Many reasons have been postulated for the differences between adult and pediatric analgesic utilization.1,2,7,8 Although prevalent in past years, there remains an assumption among some providers that children, especially infants, may not experience pain with the same intensity as adults. Changes in motor activity, sleep, or normal behavior patterns may be a reflection of pain. Crying by infants or young children may be perceived as general discomfort or unhappiness, as opposed to pain. The inability to verbalize the experience of pain may also be a contributing factor. Some providers may still be hesitant to use narcotic analgesics because of their association with addiction or respiratory depression.
Previous studies have shown that in addition to receiving less analgesia, pediatric patients were less likely to receive narcotic analgesia.1,3,4 In our study, there was no difference in the provision of narcotic pain medication in the ED to adults as compared with children. However, pediatric patients were less likely to receive discharge narcotic analgesia than adults. Pediatric patients were also more likely to experience under dosing of their discharge medication. It appears that although progress has been made in the use of narcotic analgesia for significant pain in the ED, there are still barriers to the provision of such pain medication after discharge.
Our data reveal some differences in analgesic utilization among different types of ED settings. A study by Lewis et al7showed no difference in utilization between rural and urban EDs, or between teaching hospitals (defined as having residents in the ED) or nonteaching hospitals. No other studies were identified which examined analgesic use in different types of EDs. In this study, it is intriguing to note the significant decrease in analgesic use by the COMTY ED compared with the COMB ED and the strong, although not statistically significant, trend toward decreased use when compared with the SEP ED. It is possible that the relatively more academic settings of the COMB ED and SEP ED, which have major training programs, are associated with providers who are more familiar with the literature related to analgesia. This increased awareness may be a factor which contributes to improved utilization.
Although pediatric patients received less analgesia than adults at the COMB ED and COMTY ED, this difference did not persist at the SEP ED. This lack of difference between pediatric and adult analgesic use at the SEP ED may reflect a combination of a somewhat higher use in the pediatric and lower use in the adult population compared with the other ED settings. However, it appears that pediatric ED analgesic use was significantly higher at the SEP ED when compared with the COMTY ED. The pediatric faculty at the SEP ED are all sub board eligible or certified in pediatric emergency medicine. Although much of the care in this setting was provided by pediatric residents, it may be that familiarity among the faculty with recent literature regarding ED analgesic use contributed to better utilization in children. Nevertheless, it is interesting to note the lack of difference in analgesic utilization between providers at different levels of training. It is conceivable that the overall academic environment established by the faculty may be transmitted to other providers of emergency care.
It is also interesting to note that although the mean time from triage to provision of analgesia was the same between pediatric and adult patients, analgesia was provided much more rapidly in the COMTY ED. It is unknown whether this represents a true difference in provision of analgesia or is a reflection of an overall increase in efficiency, decrease in acuity, or other factors at the COMTY ED.
Inasmuch as part of the study by Selbst and Clark5examined a subgroup consisting of patients with lower extremity fractures, we were interested in comparing those data, gathered between 1987 and 1988, with our current data (Fig 3). In addition, their data was divided into children (0 to 17 years), adults (18 to 65 years) and senior citizens (66 years and older), allowing for appropriate comparisons by eliminating their senior citizen cohort. Although adult analgesic use in the ED appears to have significantly increased (12/39; 31% vs 88/120; 73%; P< .001), pediatric use has not (8/24; 33% vs 64/120; 53%;P = .08). In addition, comparing discharge analgesic use reveals a significant decrease in differences between pediatric and adult patients (Fig 3). However, while there is no difference between previous and current discharge analgesic use in adults (9/12; 75% vs 102/120; 85%) (P = ns), pediatric patients are receiving significantly more discharge analgesia than in the past (3/13; 23% vs 93/120; 78%) (P < 0.001). Overall, while some differences in adult and pediatric analgesic use remain, it appears that such use is increasing. One possible explanation for this improvement might be the surge in recent literature on this topic.
It is important to acknowledge the limitations of this study. The retrospective design has obvious limitations in data collection. Without a prospective design, it is impossible to characterize patients' pain and to maintain control over study variables. This problem is exacerbated when attempting to compare two retrospective studies. Nevertheless, we felt the prior work by Selbst and Clark5 to be sufficiently analogous to parts of our data to allow for a valid comparison. In addition, we have no way to assess how well analgesic use actually resulted in reduction of pain.
Another possible limitation relates to the generalizability of our study. There are potentially substantial differences between different academic and non academic emergency departments which may impact on the utilization of analgesia. In addition, geographic variation may exist with respect to several of the parameters studied. A larger study with more institutions over a wider geographic area would be needed to address this limitation.
Although analgesic utilization has improved over time, ED analgesia is still used less frequently in the pediatric compared with the adult population. Whereas the use of discharge analgesia in children has improved, inadequate dosing remains a significant problem. Patterns of analgesic utilization may differ in different types of ED settings.
- Received March 27, 1996.
- Accepted July 10, 1996.
Reprint requests to (E.M.P.) Department of Pediatrics, Rainbow Babies and Childrens Hospital, 11100 Euclid Ave, LKS, 1500, Cleveland, OH 44106.
- ED =
- emergency department •
- SEP ED =
- separate pediatric and adult EDs •
- COMB ED =
- combined adult and pediatric ED •
- COMTY ED =
- community hospital with a combined ED
- Schechter NL,
- Allen DA,
- Hanson K
- ↵Eland JM, Anderson JE. The experience of pain in children. In: Jacox A, ed. Pain: A Source Book for Nurses and Other Health Professionals. Boston, MA: Little, Brown & Co; 1977
- ↵US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Acute Pain Management: Operative or Medical Procedures and Trauma. Washington, DC: US Department of Health and Human Services; 1992
- Copyright © 1997 American Academy of Pediatrics