Background

There are a large number of established pain assessment tools, encompassing various methods of measurement for use by different age groups. Although the majority of these tools have been subject to some form of statistical analysis, none has been validated specifically for use in the A&E setting where the environment is stressful and tense and children are using these tools for the first time.

We developed a tool using a combination of existing methods for use by both verbal and pre-verbal children, and then set out to establish its inter-observer reliability and validity. Figure 1 shows the developed pain assessment tool.

The tool comprises a mixture of both subjective and objective measurement, along with an example of the type of injury. The child is first asked to choose both a face and a number most appropriate to their degree of pain. The nurse then circles the most fitting behaviour seen in the child. It may be that these behaviours lie across a variety of columns. The injury example serves as a reminder to the nurse or other healthcare professional about the likely severity of pain, especially given their knowledge of potential investigations, such as x-rays which will involve a certain amount of movement. Once all this information has been collected, the nurse attributes the best-represented category of 'no pain', 'mild pain', moderate pain' or 'severe pain'.

Analgesia algorithm

Inter-observer reliability

We then set out to establish the reliability of the tool. The pain assessment tool was put into use in the A&E Department for a period of three months: from January to March 2002, to enable the nursing staff to become familiar with its use. After this period, data was collected in order to establish the tool's inter-observer reliability. Two nurses were involved with each assessment, but a mixture of methods was used in order to minimise any potential bias. In phase one, two nurses assessed the child and completed the assessment tool consecutively and independently of each other. In phase two, nurse one questioned the child while nurse two observed. Both completed a pain score independently.

Results

Sixty-five children were included in the study; two assessments were discarded from the analysis as they were incomplete.

Phase 1 results of inter-observer reliability audit.

Statistical analysis and the calculation of kappa values showed that for phase 1 the kappa value was 0.44 (95% CI  0.25 - 0.63) signifying fair agreement. For phase two, the kappa value was 0.79 (95% CI  0.44 -1.15) signifying an excellent agreement.

Having successfully proved a good degree of inter-observer reliability, the next stage of the project was to try to prove some form of validity, in other words whether the tool measures what it reports to measure. The data for this stage was collected over a one-month period and included 51 children. During the validation period, all children presenting to A&E with a painful condition were assessed by the assessment nurse using the new tool and a pain score selected.

Analgesia was then given according to the algorithm (Figure 2). Each child was reassessed following analgesia and the new pain score documented.

Comparison of assessment post-analgesia with initial assessment:

• Decreased in pain score      59%
• No change in pain score      37%
• Increase in pain score            4%

The children included in the study all demonstrated good use of the pain assessment tool, and the majority showed a decrease in their pain score following analgesia. The staff working in the department found this tool more reliable, as it allows for self-report from the child, input from the assessing member of stuff, as well as taking the injury or illness into account.

All the children included in the study also had the type of analgesia they received documented. Although the majority showed a decrease in their pain score, when collating the data it became apparent to us that many of the children were not given the maximum appropriate analgesia as defined in the algorithm. If all the children had received adequate analgesia according to their initial pain score the percentage of children showing a reduction might have been higher. However, a number of factors were not specifically taken into account.

During the validation period, all children presenting to A&E with a painful condition were assessed by the assessment nurse using the new tool and a pain score selected.

Any analgesia given to children prior to their attendance at A&E was not documented nor was their past medical history, which in the case of asthmatics would indicate a reason why Ibuprofen or Diclofenac was not given. Similarly, the second assessment did not take into account any non-pharmacological interventions that had occurred since the initial assessment: such as the application of splints, backslabs or dressings. While it is impossible to predict the impact of the inclusion of such data in the study, it is vital to note that if it had been included the results may have been different.

In practice since then, this pain tool has proved to be a reliable method of assessment of paediatric pain in the A&E setting. Inter-observer reliability has been proved, along with a degree of validation. Further audit of this tool now needs to be completed taking into account all the factors highlighted, as well as establishing whether it is more widely used by nurses as part of the assessment process.

References

1. Department of Health. Reforming Emergency Care. London, DOH, 2002.

2. Royal College of Nursing. Recognition and Assessment of Acute Pain in Children. London, RCN, 2001.

3. Advanced Life Support Group. Advanced Paediatric Life Support. 3rd Edn. London, BMJ  Publishing Group 2001.

4. British Association for Accident and Emergency Medicine. Guidelines for Analgesia in Children in the Accident and Emergency Department. London, BAAEM,  1997.

5. Cohen J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 1960; 20:37-46.

6. Robson. Real World Research: A Resource for Social Scientists and Practitioners. Oxford, Blackwell, 1995.