Paramedics and emergency medical technicians (EMTs) identified several barriers and facilitators along with proposed methods of improvement. These were combined with previous evidence to develop a plan to improve the quality of care for children suffering acute pain in the pre-hospital setting.
Barriers and facilitators
Many of the identified barriers and facilitators within the management, emotional, social, organisational and knowledge and experience themes had previously been identified [14, 30,31,32,33]. Some were considered novel in this population and setting; physical (visualisation of trauma), child shame, child embarrassment, clinician empathy, the child’s prior experience of pain, the clinician’s life experience, service demand and environmental factors (light, noise and colour).
Shame experienced by children, particularly adolescent children, has been studied in sport, where adolescent athletes have a fear of failure and subsequently a fear of shame and embarrassment [34]. Shame typically leads individuals to hide, deny or escape interpersonal interaction [35]. This may explain why shame was identified as a barrier, as children may be less likely to interact fully with the clinician and perhaps less likely to truthfully report pain. Shame may also explain why male children are more likely to achieve effective pain management than female children in the pre-hospital setting, [12] as our previous study suggested male children may display more ‘bravado’ [21], thus skewing pain scores.
Clinician empathy was identified as an influencing factor. Patients attended by clinicians with high levels of empathy are significantly more likely to have reduced severity and duration of illness [36] and are more likely to retain information and comply with self-administration of medication [37]. Maintaining empathy can be difficult; the findings of this study highlighted a number of factors that can influence the clinician’s level of empathy, including health status, run of shifts, job types, how busy the clinician has been and the time of day or night.
Environmental factors such as light and sound were identified as influencing factors, but evidence to support this was sparse. The physiological impact of light on pain is not clear. One study showed that supplementary bright light and even low light was effective at reducing pain intensity in adults suffering nonspecific back pain [38]. Animal studies have shown green light to be a promising mechanism to promote antinociception [39]. The optimum brightness and colour of light to promote effective pain management is currently unknown and requires more research. Audio-analgesia, the use of sound to suppress pain, has also been described extensively, [40, 41] with white noise being used to soothe new-born babies for example [42]. The impact of noise from crowding or from the ambulance or medical equipment on pain perception is less clear and requires further research.
Proposed improvements
Some of the proposed methods for improvement had previously been identified, such as use of intranasal analgesics, topical numbing creams, enhanced education and enhanced pain assessment [14, 30,31,32]. Several were considered novel; lollipops, analgesic lollipops, cartoon videos, methoxyflurane (Penthrox®), non-opiate analgesics, and electronic clinical records (to facilitate pain assessment).
The interaction between sugar and pain in children has been researched extensively; the effectiveness of sugar for treating pain in neonates was confirmed in a recent systematic review [43]. Oral glucose was effective at reducing distress in infants up to the age of 12 months [44]. Intraoral sucrose may be effective at reducing pain in pre-pubescent children [45] and sucrose was effective at increasing the pain threshold and tolerance in children aged 5–10 years [46]. The combination of an active analgesic agent (fentanyl) coupled with the sugar (sucrose) of a lollipop is therefore an appealing intervention. In the acute setting, emergency department studies showed that fentanyl lollipops were effective in children at reducing pain [47, 48] and two battlefield studies [49, 50] concluded that oral transmucosal fentanyl citrate provided rapid non-invasive analgesia that was safe and effective in injured army casualties. Further research is required to determine the safety and efficacy of oral transmucosal fentanyl citrate for children in the pre-hospital setting.
Methoxyflurane has been utilised in Australia for pre-hospital child pain management for many years [51] and is currently undergoing a clinical trial within the UK to determine efficacy and safety in children [52]. Methoxyflurane may have the potential to replace nitrous oxide (Entonox®) as the pre-hospital inhaled analgesic of choice within the UK as it is less cumbersome and more child friendly.
Topical creams are effective at reducing pain in children during needle insertion [53]. The concern for pre-hospital use is the delay in action. When a child is suffering acute illness or injury, rapid interventions are necessary to reduce suffering and facilitate extrication and transport to hospital. Consideration should also be given to onward care; it would be useful for the hospital to be able to cannulate the child after arrival if further analgesics or other drugs are required.
Optimum crew mix was discussed by participants; having a regular crewmate was considered important, with many stating that it makes difficult cases easier to manage as clinicians are familiar with each other and their working practices are well rehearsed, so they can focus on the patient. One study found that having a regular crewmate enhanced the psychological coping strategies of critical care paramedics when dealing with life threatening events [54]. This may make coping with similarly stressful situations, such as managing a child with severe acute pain, easier. Clinician sex mix was also deemed important by participants, as male and female colleagues may have differing approaches. Children and parents may have differing views on the sex of the attending clinicians; Waseem and Ryan [55] studied 200 children (70% male) aged 8 to 13 years attending a paediatric emergency department for laceration repair. They found that 79% of children who needed a suture in the emergency department would prefer to be treated by a female doctor (whereas 60% of parents preferred a male doctor). Jepsen and Rooth et al [13] found that parents of children attended by ambulance perceived female clinicians to provide more confident and more natural care for their children.
The combination of having a crew of clinicians who work together regularly, who are of opposite sex and contain at least one paramedic could improve rates of effective pain management in children suffering acute pain. Further research exploring the perceptions of children and parents would be ideal to help develop a theory for the ‘optimum crew’ mix.
Driver diagram
The driver diagram, illustrated in Fig. 3, showed that rates of effective pain management may be enhanced by increasing rates of analgesic administration and reducing child and clinician fear and anxiety. Inhaled (e.g. methoxyflurane) and oral (e.g. lollipops) routes have been discussed above. Studies have shown that the introduction of intranasal fentanyl improves the rates of effective pain management in children suffering acute pain in the pre-hospital setting [56, 57]. A recent rapid evidence review found that intranasal fentanyl appeared to be effective and safe, but interventional data were lacking [58]. Clinical trials are needed to corroborate this finding.
Reducing fear and anxiety in children could be achieved through child friendly uniform. Whilst theoretically this is feasible, the practicalities need consideration due to infection prevention and control concerns and it would have to be a temporary item of clothing that could be donned and removed for appropriate incidents only (a tabard perhaps). Paediatric nursing staff have altered their clothing to improve the experience of children for many years, with brightly coloured uniforms preferred by children [59,60,61,62] which reduce anxiety [63, 64] and increase positive emotions, for example feeling calm, relaxed or happy [61]. There is potential for similar benefits in the pre-hospital setting.
Children attended by paramedics are more likely to achieve effective pain management than those attended by EMTs [12]. Optimum crew mix was discussed by participants; ensuring a paramedic, or highly qualified clinician, is on each emergency vehicle may help to reduce the overall fear and anxiety of the crew, as paramedics were perceived to be more confident, more experienced and have an extended scope of practice [21]. This necessitates long-term commitment to staff training and development by ambulance services.
Strengths and limitations
Many of the findings from this study were previously identified, demonstrating external validity, therefore the cumulative recommendations illustrated in Fig. 3 may be transferrable to emergency medical service settings outside of the UK. Several novel barriers, facilitators and potential methods of improvement were identified within this study; this contributes to a more comprehensive understanding of this complex phenomenon and could help to improve the quality of care.
The low number of EMT participants could be perceived as a limitation, however we felt that code and meaning saturation were achieved and that further EMT data were unlikely to provide any new insights. Due to the clinical background of the interviewer, ‘blind spots’ were a concern, [24] where seemingly simple concepts that are taken for granted may have been overlooked. Involvement of a non-clinician (GRL) and clinicians from different clinical fields including nursing (PH) and primary care (ANS), along with review from a paramedic researcher in a different ambulance service (CW – acknowledged) helped to minimise the impact of these blind spots on the analysis and interpretation.
Implications for policy, practice and research
National level initiatives that encourage the measurement of pain, strengthening the audit of pain assessment in children, should be introduced. Knowledge mobilisation strategies should be implemented within ambulance services to reduce the gap between research and clinical practice.
Clinical practice recommendations include increasing rates of analgesic administration, by utilising different analgesics and routes. Where efficacy and safety data are lacking, then clinical trials should be performed. Reducing the fear and anxiety experienced by children during emergency callouts could be achieved via child friendly uniforms, enhanced non-pharmacological distraction techniques, utilising more paediatric equipment and participating in more public interaction. Increased public interaction would allow children the opportunity to familiarise themselves with the ambulance staff, vehicle and equipment and could be achieved through attendance to schools, public events or holiday venues. Reducing the fear and anxiety experienced by clinicians could be achieved by optimising the crew mix, by having a paramedic (or highly qualified clinician) on all vehicles, ensuring male and female crews where possible and allowing crews to work together on a regular basis. Pragmatic pain assessment tools for children in the pre-hospital setting should be explored, developed and implemented and paediatric training should be enhanced.
Future research should involve children and their parents to explore their experiences, determine the most important outcome measures and co-produce interventions to improve the quality of care.
