Aim To assess whether the trust's multidisciplinary guideline on pain management in children1 is being adhered to.
Method A data collection tool was designed, piloted on 4 patients, and then adapted for use in the audit. Data were collected on 59 inpatients over 2 weeks; Paediatric Intensive Care Unit patients and those with Patient or Nurse Controlled Analgesia were excluded.
The standards for the audit were set at 100%. The 4 standards were:
All patients to have a documented pain score, as measured by the trust specific pain score documented in the guideline.1
All doses to be calculated correctly in line with the dose table included in the guideline.1
All analgesics prescribed to be in line with those included in the guideline.1
Correct doses of naloxone and anti-emetics to be prescribed for all patients receiving opiates, to pre-empt opiate induced side-effects, in line with the guideline.1
Results The number of patients with a pain score documented was 58/59 (98%); from a total of 526 scores, 480 (91%) had used the trust specific pain score. 390 (74%) scores were zero, i.e. the patient had no pain.
A total of 91 analgesics were prescribed; in 88 (97%) cases the drug was appropriately chosen from the guideline. Two prescriptions were for codeine which is not included in the guideline following recent guidance about variable metabolism of codeine in children.2 One patient was prescribed pregabalin for neuropathic pain, this was appropriate, but not currently in the guideline.
In the case of paracetamol, 17/49 (35%) of doses were correctly calculated. For ibuprofen 9/21 (43%) of doses were correct, and for morphine 12/18 (67%) were correct.
In practice 5/18 (28%) opiate doses were prescribed with naloxone in case of respiratory depression, 2/18 (11%) were prescribed with naloxone in case of pruritis, and 8/18 (44%) were prescribed with anti-emetics.
Conclusion Overall there was good compliance with pain scoring and good adherence to the guideline for drug choice. However, the doses calculated for analgesics rarely conformed to the dosing table in the guideline. This is suspected to be because the doses in the guideline are at the high end of dose ranges recommended in the BNFC. Anti-emetics and naloxone were infrequently co-prescribed with opiates, contrary to the guideline. These are the two main areas for improvement identified.
The suggested methods for improvement are; to prepare teaching sessions for the junior doctors on pain management; to publicise dosage tables from the guideline by laminating them and having them available on the wards at the point of prescribing; presenting the findings of the audit at the next paediatric audit afternoon, and possible inclusion of gabapentin/pregabalin in a future version of the guideline.