Valutazione e trattamento del dolore in Pronto Soccorso Pediatrico: efficacia di diverse strategie di miglioramento

Il dolore risulta presente nel 70-86% delle visite di Pronto Soccorso (PS). Nonostante il proliferare di linee guida e gli sforzi per considerare il dolore come un segno vitale, rimane ancora sotto-valutato e sotto-trattato. La registrazione del dolore \ue8 inadeguata fra i servizi dell\u2019emergenza territoriale e nei PS, essendo documentata nel 15/52% dei casi. In Italia solo il 26% dei bambini viene valutato per il dolore al momento del triage e, in 1/3 dei casi, senza l\u2019uso di scale validate. Inoltre, circa il 50% degli ospedali non \ue8 provvisto di protocolli sulla gestione del dolore. Anche nei in casi in cui il dolore stesso \ue8 la ragione di accesso al PS, la valutazione del dolore \ue8 bassa (40%) e farmaci analgesici sono somministrati in PS solo in 1/3 dei casi. Le conseguenze fisiche e psicologiche del dolore non trattato son ben note, sia nel breve che nel lungo termine. Gli aspetti emotivi e psicologici del dolore coinvolgono le abilit\ue0 cognitive e dello sviluppo dei bambini, non essendo essi in grado di comprendere lo scopo finale di una procedura dolorosa. Le pi\uf9 frequenti barriere per una gestione adeguata del dolore sono state identificate nella scarsa formazione dei sanitari e nell\u2019assenza di protocolli che guidino la valutazione e il trattamento del sintomo. Diverse strategie di implementazione sono state studiate, ma non vi \ue8 ancora concordanza sulla diversa efficacia delle suddette strategie. Scopo di questo studio \ue8 applicare diversi approcci e diverse strategie alla stessa popolazione per identificare il miglior approccio e confrontare la loro efficacia nell\u2019aumentare la percentuale di valutazione, trattamento e rivalutazione. Nella prima fase abbiamo modificato il software informatico del PS, in modo da rendere la valutazione del dolore obbligatoria al momento del triage. Nella seconde fase abbiamo aumentato il numero delle infermiere dedicate al PS e strutturato un programma di formazione indirizzato a tutti i medici e alle infermiere. Nella terza fare abbiamo adottato un protocollo di autonomia infermieristica per rendere maggiormente indipendente il personale infermieristico nella gestione del dolore. La valutazione obbligatoria del dolore ha portato ad una riduzione della percentuale di trattamento, mentre la formazione e la riduzione del carico lavorativo \ue8 stata di grande utilit\ue0 nell\u2019aumentare la percentuale di bambini trattati. Nel nostro contesto, il protocollo di autonomia infermieristica \ue8 risultato essere di nulla utilit\ue0. Il limite principale di questo studio consiste nella suo disegno retrospettivo che lo rende suscettibile alla perdita di dati, in particolare la mancata registrazione sui referti della valutazione e del trattamento del dolore. Ad ogni modo lo studio evidenzia l\u2019importanza e l\u2019efficacia della formazione degli operatori e della riorganizzazione del carico di lavoro, mentre i protocolli e la valutazione obbligatoria sono di limitata utilit\ue0 quando non associati alla formazione ed alla conoscenza.Pain is reported in 70-86% of Emergency Department (ED) admissions1,2. Despite the proliferation of guidelines and the efforts to consider pain as a vital sign3, it remains under-evaluated and undertreated. Pain recording is inadequate among Emergency Medical Services (EMS) and in the ED, only being documented in 15-52% of cases4. In Italy, only 26% of children are assessed for pain during triage and, in 1/3 of cases, validated pain scales are not used. Moreover, almost 50% of hospitals do not have protocols for pain management5. Even when pain is the main reason for seeking emergency care, pain assessment at triage is low (40%) and analgesics are administered in the ED in only 1/3 of the children6. The physical and psychological consequences of untreated pain are well known, in both the short- and long-term7. The emotional and psychological aspects of pain affect the development and cognitive abilities of children, because they are unable to understand the purpose of a painful procedure. The most frequent barriers to an adequate pain management have been identified in the lack of education of the healthcare providers and in the absence of protocols guiding the evaluation and the treatment8\u201314. Different strategies of implementation have been studied, but there is not agreement about the different efficacy of the different strategies. Aim of this study is to apply different approaches and different implementation strategies to the same population in order to identify the best approach and compare their efficacy in increasing the rate of pain evaluation, treatment and re-evaluation. In the first phase we adapted the ED software, making pain evaluation mandatory at triage. In second phase we increase the number of nurses per shift and we structured a peer education program addressed to all doctors and nurses. In the third phase we adopted a Nurse Initiated Analgesia protocol to enhance nurse autonomy in pain management. Mandatory pain assessment resulted in a decreased percentage of pain treatment, while education and reduction of the workload (phase two) was highly useful in increasing the rate of children treated. In our particular setting, NIA protocol appear to be useless. The main limit of this study is its retrospective nature which make the results susceptible to loss of data, in particular of the underreporting of evaluation and treatment in the ED chart. Anyway, this study highlights the importance and efficacy of providers education and reorganization of workload, while protocols and mandatory assessments are of limited usefulness when not associated to education and knowledge

Measuring empathy in pediatrics: validation of the Visual CARE measure

Background: Empathy is a key element of “Patient and Family Centered Care”, a clinical approach recommended by the American Academy of Pediatrics. However, there is a lack of validated tools to evaluate paediatrician empathy. This study aimed to validate the Visual CARE Measure, a patient rated questionnaire measuring physician empathy, in the setting of a Pediatric Emergency Department (ED). Methods: The empathy of physicians working in the Pediatric ED of the University Hospital of Udine, Italy, was assessed using an Italian translation of the Visual Care Measure. This test has three versions suited to different age groups: the 5Q questionnaire was administered to children aged 7–11, the 10Q version to those older than 11, and the 10Q–Parent questionnaire to parents of children younger than 7. The internal reliability, homogeneity and construct validity of the 5Q and 10Q/10Q–Parent versions of the Visual Care Measure, were separately assessed. The influence of family background on the rating of physician empathy and satisfaction with the clinical encounter was also evaluated. Results: Seven physicians and 416 children and their parents were included in the study. Internal consistency measured by Cronbach’s alpha was 0.95 for the 10Q/10Q–Parent versions and 0.88 for the 5Q version. The item-total correlation was > 0.75 for each item. An exploratory factor analysis showed that all the items load onto the first factor. Physicians’ empathy scores correlated with patients’ satisfaction for both the 10Q and 10Q–Parent questionnaires (Spearman’s rho = 0.7189; p < 0.001) and for the 5Q questionnaire (Spearman’s rho = 0.5968; p < 0,001). Trust in the consulting physician was lower among immigrant parents (OR 0.43. 95% CI 0.20–0.93). Conclusions: The Visual Care Measure is a reliable second-person test of physician empathy in the setting of a Pediatric Emergency Room. More studies are needed to evaluate the reliability of this instrument in other pediatric settings distinct from the Emergency Room and to further evaluate its utility in measuring the impact of communication and empathy training programmes for healthcare professionals working in pediatrics