Lord Bill, Jennings Paul A, Smith Karen
From the School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Maroochydore DC, Queensland.
Department of Community Emergency Health and Paramedic Practice, Monash University, Clayton.
Pediatr Emerg Care. 2019 Nov;35(11):749-754. doi: 10.1097/PEC.0000000000001376.
Children are at risk of inadequate analgesia due to paramedics' inexperience in assessing children and challenges in administering analgesics when the patient is distressed and uncooperative. This study reports on the outcome of a change to practice guidelines that added intranasal fentanyl and intramuscular morphine within a large statewide ambulance service.
This retrospective study included patients younger than 15 years treated by paramedics between January 2008 and December 2011. The primary outcome of interest was the proportion of patients having a 2/10 or greater reduction in pain severity score using an 11-point Verbal Numeric Rating Scale before and after the intervention. Segmented regression analysis was used to estimate the effect of the intervention over time. A multiple regression model calculated odds ratios with 95% confidence intervals.
A total of 92,378 children were transported by paramedics during the study period, with 9833 cases included in the analysis. The median age was 11 years; 61.6% were male. Before the intervention, 88.1% (n = 3114) of children receiving analgesia had a reduction of pain severity of 2 or more points, with 94.2% (n = 5933) achieving this benchmark after intervention (P < 0.0001). The odds of a reduction in pain of 2 or more points increased by 1.01 per month immediately before the intervention and 2.33 after intervention (<0.0001).
This large study of a system-wide clinical practice guideline change has demonstrated a significant improvement in the outcome of interest. However, a proportion of children with moderate to severe pain did not receive analgesia.
由于护理人员在评估儿童方面缺乏经验，以及在患者痛苦且不配合时给予镇痛药面临挑战，儿童存在镇痛不足的风险。本研究报告了一项实践指南变更的结果，该变更在一个大型全州范围的救护服务中增加了鼻内芬太尼和肌肉注射吗啡。
这项回顾性研究纳入了2008年1月至2011年12月期间由护理人员治疗的15岁以下患者。主要关注的结果是使用11点言语数字评定量表在干预前后疼痛严重程度评分降低2/10或更多的患者比例。分段回归分析用于估计干预随时间的效果。多元回归模型计算了95%置信区间的比值比。
在研究期间，护理人员共运送了92378名儿童，其中9833例纳入分析。中位年龄为11岁；61.6%为男性。干预前，接受镇痛的儿童中有88.1%（n = 3114）疼痛严重程度降低了2分或更多，干预后这一比例为94.2%（n = 5933）（P < 0.0001）。在干预前，疼痛降低2分或更多的几率每月增加1.01，干预后增加2.33（<0.0001）。
这项对全系统临床实践指南变更的大型研究表明，所关注的结果有显著改善。然而，仍有一部分中重度疼痛儿童未接受镇痛治疗。
