Name
Stacey Brown 

Role
Trainee Advanced Paediatric Nurse Practitioner 

Place of work
Paediatric Emergency Department, East Lancashire Hospitals NHS Trust 

Background 
Pain is subjective and children often do not have the cognitive development, language development or maturity to articulate the severity of their pain. The Royal College of Emergency Medicine (2013) recommend the use of the following:

• A multi age and cognition pain assessment tool
• Guidelines for choice of appropriate analgesia
• Reassessment within 60 minutes of administered analgesia

 
A retrospective audit of 29 children with suspected fractures was undertaken in the Paediatric Emergency Department and highlighted poor pain assessment as part of the triage process. A Staff training analysis demonstrated poor staff knowledge and little confidence in paediatric pain assessment.
 
Research suggests inadequately managed pain can create a poor experience for the child and their family and can lead to long term psychological difficulties, chronic pain conditions and a negative experience for the child.
 
Aim 
To ensure children attending the Emergency Department with limb injuries have their pain effectively assessed at the point of triage, appropriate analgesia administered and reassessment within 60 minutes of administration by appropriately trained staff through the use of bundle.
 
Method 
Using Kotter’s ‘8 step change model’ to guide the implementation of a paediatric pain assessment bundle.

• Key stakeholders identified and fully engaged
• Bundle peer reviewed
• Take home leaflet for managing children’s pain at home
• Department and trust governance approval granted for pilot.
• Staff training on Pain assessment through micro teaching and teaching packs
• Online Entonox training from gas supplier introduced
• Diclofenac availability approval by pharmacy
• Ensuring all PGD’s current and completed by staff

 
Evaluation 
Continual evaluation will be carried out and a re-audit measured against the same standards (RCEM, 2013). The audit examined if pain assessment was completed at first point of triage, appropriate analgesia administered based on pain score and re-assessment within 60 minutes of administration of analgesia. A staff training questionnaire measured staff knowledge and confidence with patient feedback obtained through friends and family cards.
 
Conclusion 
The Paediatric pain assessment bundle ensures children visiting the Emergency Department are being cared for efficiently and receiving optimum care. Children often attend hospital with a primary complaint of pain.
 
This change in practice will safeguard and ensure children are having their pain effectively managed, reassessed and advised how to manage at home by well trained and competent staff, thus creating a positive hospital experience for the child.
 
Three key learning points  
1. Engaging stakeholders early in the change process is essential to the success of the change
2. An approved pain assessment bundle will reduce mismanagement of pain in children and eradicate uncertainties in choice of analgesia, sustainability is dependent on keeping the topic current
3. Identifying ‘champions’ early in the change process enables continuity and assurance staff remain motivated

Name
Joanne Watson 

Role
Trainee Paediatric Advanced Nurse Practitioner 

Place of work
Paediatric Emergency Department, East Lancashire Hospitals NHS Trust  

Background  
Diarrhoea and/or vomiting is a common manifestation of acute gastroenteritis and is a leading cause of emergency attendances in children (Fedorowicz, Jagannath & Carter, 2011).
 
The primary focus in caring for those who attend paediatric ED/UCC is the early detection of dehydration. Tian, Dixon and Gao (2012) highlight that timely interventions will prevent deterioration and reduce admissions; dehydration and gastroenteritis account for 10.4% of emergency admissions.
 
Appropriate fluid challenge, in a timely manner, in order that dehydration or further deterioration of dehydration is prevented is ‘gold standard’. There are however, still variations in practice. An audit using the NICE (2009) five standards was performed over a three-month period to capture those attending ED/UCC under the age of five, with a primary diagnosis of gastroenteritis. The results showed limited, documented compliance with NICE (2009) guidelines; recording of weights, fluid challenges and dehydration scores were found to be particularly poor.
 
Aim  
To develop a care bundle for children attending the ED with gastroenteritis using NICE (2009) standards and introduce within the department to reduce variation and standardise care.
 
Method  
Kotter’s (2012) leading change theory was used to provide structure in adopting and instilling a more proficient way of managing gastroenteritis in the under-fives. Stakeholder involvement, acceptance and support were sought and a teaching package developed to ensure clinical staff compliance. Two “staff Champions” were selected to aid the change process.
 
Evaluation 
Donabedian’s (2005) structure, process and outcome framework was used in evaluating the effectiveness of the change in practice. A re-audit was undertaken on a four-weekly basis with measurement and evaluation of the baseline standards including staff compliance. Appropriateness and length of admissions was evaluated at the end of the pilot phase.
 
Conclusion  
Current practice required a shift towards a more proactive management of gastroenteritis care. The introduction of the bundle has ensured that evidence-based care is being instilled into everyday practice.
 
Three key learning points  
1. Early implementation of a fluid challenge in the ED will prevent further deterioration of the condition due to dehydration.
2. Staff resistance to change makes the implementation of the bundle difficult
3. Staff, parents/carers need to change their perception of the most appropriate fluid challenge required to manage the condition and therefore reduce admissions and facilitate safe discharge.