Barriers and facilitators to out-of-hospital pain management for children

Search strategy and terms

To ensure key articles were identified, various index and keywords in context search terms were identified and developed into a search string (Table 1). Search terms were applied to three databases (CINAHL, MEDLINE and PsycINFO) using the EBSCO platform.

Huang et al (2006: 359) identified that population, intervention, comparison and outcome are essential components of an effective search strategy. This method, known as PICO, encourages an evidenced-based approach when searching for literature. Search terms were selected to help ensure the relevant population i.e. in the out-of-hospital environment. The authors acknowledge that some search terms, such as ‘paramedic’ required specific expansion as it proved to be a ‘stop’ word because it is not universally adopted in international literature (Greenhalgh et al, 2003:142). Moreover, the term ‘paediatrics’ was similarly expanded so results encapsulated all age groups under 18 years, and to also ensure that results were specific to the population age (excluding adult patients). Only articles that were either published in English or available as an English translation were selected.

Searches were undertaken from 2009–2019 to ensure contemporary relevance and to account for developments in education, practice and role developments. To ensure the review was as up to date as possible, the search was rerun in 2021.

All research methods and methodologies were included to ensure breadth of data to be assessed, such as qualitative, quantitative and mixed-methods research. Eligible literature was restricted to primary research (Wilczynski et al, 2007).

Search results

Across the three databases, initial searches identified 5196 results, which were reduced to 3303 once duplicates had been removed. After inclusion and exclusion criteria had been applied, 268 papers remained, with 3035 excluded as they were secondary research or focused away from the target area (e.g. on an unrelated profession or the administration of a specific drug).

These papers were then subject to a title sift, under which 156 papers were removed as they were irrelevant to the review question.

The title/abstracts of the remaining 112 papers were then assessed to ensure suitability. After final screening, 15 papers were eligible and subject to data extraction.

Methodological issues

Model of service

Galinski et al (2011) considered the treatment of patients (aged 15 years or younger) in France, finding the prevalence of pain in children presenting to out-of-hospital services to be high (92%; 94/96), with 41% (42/96) receiving multimodal analgesia. Management and treatment efficacy was found the same across age groups, and this was comparatively high (84%), compared to the findings of other studies where an Anglo-American’ model was assessed by non-physicians at 39.5% (Jennings et al, 2015) and 26% (Murphy et al, 2016). This suggests having a doctor available would alleviate poor levels of analgesia provision when pain is reported.

However, this contrasts with Murphy et al (2016), who found analgesia administration was no lower in the ambulance service than in the emergency department where physician-led care would be instigated. In this study, agreement was found within ambulance and emergency department (ED) care that higher reported levels of pain increased the likelihood of analgesia being provided.

However, while there was linear concordance, those within ED were significantly more likely to receive analgesia regardless of the severity of the reported pain. Murphy et al (2016) report an average of 30.25% from the ambulance versus 56.25% in the ED, with the highest disparity in those reporting ‘moderate’ (41% versus 67%) or ‘severe’ pain (54% versus 100%). This suggests the presence of a physician rather than a paramedic was not a contributory factor, but rather that potential other confounding or organisational factors exist specifically in the ambulance service that are not present in the ED.

Another physician-led cohort study (Schauer et al, 2018) showed a low rate of administration for ‘milder’ analgesics such as paracetamol and non-steroidal anti-inflammatory drugs. Of 3439 traumatically injured patients, 18% (n=618) received analgesia, but a far greater rate of multimodal analgesia administration was displayed in their cohort, perhaps suggesting that, if physician care is available, patients may receive more specific care packages. However, a higher proportion of patients had a high injury severity score (ISS) and blast injury; such traumatic and high-acuity injuries skew protocols away from other general populous norms. This study was conducted in Afghanistan and Iraq during military conflict so generalisation is limited.

In the United States, where there is physician consulted models of care, Johnson et al (2014) reported higher rates of IV opioid administration. Rates of fentanyl (87.7%) and morphine (11.7%) administration were highest in all patients who received analgesia, regardless of severity. Patients had greater odds of receiving either of these if they were older, had a site providing existing intravenous (IV) access or if they were intubated. Higher age and higher Glasgow Coma Scale score were also associated with increased analgesic use in a multivariable analysis. However, a significant number of the patients were sedated, and it is difficult to differentiate between patients receiving certain medications for analgesia or sedation. However, this study was undertaken in a physician-led EMS care system and, as such, cannot be compared to the UK system.

Drug access and legal formulary frameworks

The literature highlights significant variance in the legal permissions in analgesia administration by different nations’ ambulance services. This may be partially influenced by the level of medical autonomy within systems and legal frameworks. The literature showed these frameworks and drug availability influenced decisions around patient management.

Some of the papers specifically assessed the efficacy of certain drugs as a primary aim, while in others this was a secondary outcome and discussion point (Bendall et al, 2011: Galinski et al, 2011; Johnson et al, 2014; Jennings et al, 2015: Murphy et al, 2016; 2017; Schauer et al, 2018).

Galinski et al (2011) found the most prevalent analgesics accessed were paracetamol (45%; n=43), morphine (39%; n=38), Entonox (50% nitrous oxide and 50% oxygen) (39%; n=38) and nalbuphine (18%; n=18). Morphine administration was associated with patients expressing a higher severity of pain. A total of 37% of patients deemed eligible for inclusion (n=96) said they had pain, which was treated in 90% (n=88) of cases. Relief was achieved in 80%, indicating an appropriate pharmaceutical agent choice (Galinski et al, 2011).

These findings match drugs permitted for use by paramedics within the UK, except nalbuphine, and shows higher efficacy. However, Galinski et al (2011) show higher rates of effective management of pain in comparison to countries with similar EMS services (Bendall et al, 2011; Murphy et al, 2014; 2016; 2017; Jennings et al, 2015).

Three studies were conducted in Ireland (Murphy et al, 2014; 2016; 2017), with one cohort study (Murphy et al, 2016) reporting that only 689 of 2635 eligible patients receiving analgesia. Of these 73% (n=504), received only a single agent, most commonly paracetamol (35%; n=11). While patients with a higher identified pain score had a higher incidence of analgesia administration, of the 319 with severe pain, only 12% (n=40) received morphine (Murphy et al, 2016).

However, in subsequent research by Murphy et al (2017), intranasal fentanyl (INF) was found to be a safe and effective analgesic agent to administer to children in the prehospital environment and offered an alternative to oral and IV opioids. The authors found a statistically significant reduction in pain noted for 83% (n=78) of patients who received INF and in those reported to have the highest levels of pain. No adverse effect was noted from its administration.

Drug routes available

The route of drug administration may also influence clinician decisions in providing analgesic medication (Bendall et al, 2011; Jennings et al, 2015: Browne et al, 2016b; Lord et al, 2016; Murphy et al, 2017).

Methoxyflurane has long been licensed for prehospital use in Australia, although it is not as common elsewhere, such as in the UK (Porter et al, 2018). An inhaled drug requires no invasive access, so it may potentially reduce some of the anxiety and difficulty associated with IV administration in paediatric patients (Lord et al, 2016).

In contrast to Murphy et al (2017), Bendall et al (2011) found INF and IV morphine were more effective than methoxyflurane in the treatment of paediatric pain. It was noted that INF may be preferable as it is a less invasive method of administration. However, caution is needed in reporting this study as only 3312 of >8000 identified patients were eligible for analysis because of missing data, a fundamental flaw in the internal validity of the study.

A later study by Jennings et al (2015) found methoxyflurane to be the most common agent used for paediatric patients (69.8%). Overall, administration of any agent was associated with a sixfold increase in the successful treatment of pain, with methoxyflurane associated with the greatest odds of achieving a clinically meaningful reduction in pain.

Bendall et al (2011) conducted a secondary analysis that found clinically meaningful treatment resulted in a >30% reduction in pain within the data. Most eligible patients (82.5%; n=2,733) achieved meaningful pain reduction; INF was most effective and methoxyflurane the least (89.5%; n=274 compared with 78.3%; n=1639). However, the efficacy in methoxyflurane was not less clinically significant lower than alternatives (Bendall et al, 2011).

These papers highlight disparities in the use and effectiveness of medications by out-of-hospital care providers and show that a larger formulary provision directly increases the rates and numbers of patients receiving pain relief.

These studies also highlight national differences between Australia, Ireland and the United States, Browne et al (2016b) reviewed the provision of analgesia to patients aged <18 years presenting to three EMS services in one region in the United States. After a change in drug protocol, Browne et al (2016b) permitted further analgesia options; reporting that, despite protocol change, administration of opioid medication did not deviate from the 18% recorded in their initial data (18%; 580/3597 patients compared to 18%; 644/3743). However, their findings also reported a 4% increase of administration in patients reporting a low pain score (<4/10).

This lack of increased provision of analgesia despite increased drug routes potentially alludes to other psychological or sociological barriers that inhibit the treatment of pain in children, as potential organisational restraints were in part removed by the increased drug formulary.

Age

Schauer et al (2018) identified that care providers were less likely to treat pain in children than in adults. While their assessment was solely on the traumatically injured patient, only 18% (681/3439) of identified eligible injured paediatric patients received analgesia. When assessing numerical scales for the assessment of pain, median pain for those in the ‘no analgesia’ group was 4/10, as opposed to 5/10 in the ‘analgesia’ group. This is suggestive more than the stated or assessed level of pain influenced subsequent treatment of pain or administration of analgesic agents. This was further supported by the ‘analgesic’ group noting an average ISS of 10 (5–18) (out of 75, whereby 15 constitutes major trauma), and the ‘no analgesic group’ scoring 9 (4–17). This shows that the nature or severity of an injury was not the contributary factor within these patients, but age did show a disparity. Across defined age groups, there was consistent increased analgesia administration through age groups (<1 year: 4.2%; 1–4 years; 11.7%; 5–9 years: 17.3%; 10–14 years: 21.7; 15–17 years: 21.6%).

Furthermore, Johnson et al (2014) identified that as patient age increased so did analgesic administration. Multivariable analysis showed the average age of patients receiving analgesia was 11 (7–13 years) compared to age 7 (3–12 years) in those who did not. This is corroborated by Murphy et al (2016) and Lord et al (2016), who recognised in Ireland and Australia that older patient age was associated with an increase in initial pain assessment score.

Of eligible patients evaluated by Browne et al (2016a) only 35% (n=243) had a documented pain score; 18% (n=51) of those with a pain score >4 were administered opioid analgesia, compared to 15% (n=43) of those with a score <4. Findings suggest that pain severity was not the major contributory factor in the decision to administer higher-level pain relief. This effect shown across international boundaries with a consistent age bias, so would appear to hold validity on face value. However, there could easily be mitigating factors-such as severity and pattern of injury; it is widely accepted that it may be appropriate to receive higher levels of analgesia if injuries are more severe with increasing age.

Sex

Bendall et al (2011) conducted a secondary analysis of their cohort database to assess the effectiveness of treatment protocols in Australia noting sex differences. Boys were more likely to receive analgesia but no discernible rationale for this was provided. Schauer et al (2018) also found that injured male patients were more likely to receive analgesia (498/2654; 18.7%) than female patients, fitting the same characteristics (120/785, 15.2%). Lord et al (2016) also reported that male patients were more likely to receive analgesia, albeit to a more marginal degree (40.9%; 9236 versus 37.6%; 5853).

Further evidence of potential gender influence is reported by Galinski, et al (2011) whose data showed that female patients were less likely to receive opioid medications. This is despite no difference in the incidence of severe pain (accounting for sex, age or disorder type) compared with the absence of pain in girls or boys.

This influence was consistent across international boundaries, so would appear to hold validity on face value. However, the reasons for this are unexplained or not reported, so to determine absolute cause and effect is impossible on the data presented.

Ethnicity

Johnson et al (2014) explored whether ethno-demographic disparity was a contributory factor to poor analgesic management. After controlling for important clinical confounders, such as injury severity, though this ‘was not found to be significant’ (2014: 533), Johnson et al (2014) found that 41.2% (n=4215) of Caucasian patients had pain assessment documented, compared to 26.8% (n=721) of patients from other ethnic backgrounds, and that 15.4% (n=649) of Caucasian patients received analgesia compared to 10% (n=72) of patients with other ethnic backgrounds.

When accounting for percentile differences, across ethnicity groups, the same proportion of those who had pain documented were given analgesia (with 37% of both groups subsequently receiving analgesia). It is not possible to identify the root cause why patients with a non-Caucasian ethnic background were less likely to have their pain formally assessed.

Johnson et al (2014) also reported that, after adjusting for confounders, no evidence of racial differences in the analgesic agents provided was noted.

Fear of error

The potential for or fear of making a mistake in judgement, dosing or treatment had a psychological influence upon decision-making when treating paediatric pain.

Rahman et al (2015) identified barriers to the provision of analgesia to paediatric patients, which included a fear of dosing errors, concerns about adverse effects, as well as reduced prevalence of exposure to situations/circumstances when the administration of pain relief was necessary.

Similar factors were also identified by Williams et al (2012) showing concordance across the north American countries and systems, although education and regulation standards of clinicians are different between regions. However, EMS system set-ups, particularly within Canada (Rahman et al, 2015), share large consistencies with the UK. Williams et al (2012) found 13/16 participants identified perceived ‘success’ with paediatric analgesia at least once in their careers and scored their ‘comfort’ in treating as 6/10.

Unfamiliarity with protocols was consistently highlighted as an area of concern.

Limited experience and education

Rahman et al (2015) identified that ‘lesser trained’ clinicians (identified as primary care paramedics rather than advanced care paramedics) reported higher confidence in the treatment of paediatric pain, suggesting that education is not the main contributing factor. Similarly, participants within Murphy et al's (2014) study also stated that advanced paramedic education and training was heavily focussed on adult patients, limiting exposure to children through education. Attributing the difference in administration between adult and paediatric analgesia to fear of dosing errors and adverse effects in child patients in Ireland, as well as the reduced prevalence of exposure may be further contributory factors.

Rahman et al (2015) identified other common barriers, such as limited paediatric clinical experience (34%,; 37/110), difficulty in communication (21%; 23/110), and a belief that children required less analgesia because of immature nervous systems (25%; 37/147). Williams et al (2012) also found clinicians preferred to defer treatment to ongoing care providers.

Across all three qualitative papers (Williams et al, 2012; Murphy et al, 2014; Rahman et al, 2015), there was a common lack of familiarity with this patient group, which influenced the care administered.

As previously stated, the evidence reported from this review suggest various patient-related factors affect pain relief in different countries. Lord et al (2016) highlighted that paramedics lacked familiarity with paediatric patients, which they attribute to the education system in Australia. This may have contributed to their ability to competently assess and treat children in pain.

These findings show the perception that education and exposure to given conditions have upon the confidence of individual clinicians in assessing and treating paediatric patients in pain.