The Gap Between Pediatric Emergency Department Procedural Pain Management Treatments Available and Actual Practice

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Abstract
To describe the spectrum of procedures performed and the pain management methods used in our pediatric emergency department. Encounter records were retrospectively reviewed for all patients presenting to our pediatric emergency department, a stand-alone pediatric department with 20,000 patient visits per year, located in an urban, public teaching hospital, between March and June 2004. Data collected included patient demographics, provider type, procedures performed, and pharmacological pain management methods documented used. For intravenous catheter placement, the time lag between order and placement was noted. There were 1727 procedures performed in 1210 patients (18% of the total 6545 patients seen). Few to no patients undergoing venipuncture, intravenous catheter placement, fingersticks, intramuscular or subcutaneous injections, urethral catheterization, or nasogastric tube placement received pain management. The median time between order and placement of intravenous catheters was 30 minutes. Nearly all patients undergoing fracture reductions received procedural sedation with ketamine, and most of the lacerations repaired with sutures and nail avulsions received injected local anesthetic. Pain management of abscess incision and drainage and lumbar punctures was more variable. For lumbar punctures, of the patients aged 4 months or younger with a procedure note written, only 29% (7/24) had pain management documented versus 85% (22/26) of those aged 1 year or older (P < 0.0001). Several minor painful procedures are commonly performed in the emergency department without pharmacological pain management. There remains a gap between what we know to be effective, easily implemented pain management strategies, and what is actually practiced. We must work to close this gap.

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