The Effect of Music-Moving Toys to Reduce Fear and Anxiety in Preschool Children Undergoing Intravenous Insertion in a Pediatric Emergency Department: A Randomized Clinical Trial

IntroductionIntravenous catheter insertion is a highly invasive medical procedure that causes fear and anxiety in children. This study aimed to analyze the effect of a toy (with music and movement) distraction method on fear and anxiety in children aged 4 to 6 years.MethodsThis experimental, randomized clinical trial used parallel trial design guided by the Consolidated Standards of Reporting Trials checklist. Using simple randomization, eligible children (age 4-6; N = 60) were assigned to the intervention group (n = 30), who received the toy distraction method, or to the control group (n = 30), who received standard care. The Children’s Fear Scale was used to evaluate the fear levels, and Children’s State Anxiety Scale was used to evaluate anxiety levels. Physiological parameters (pulse, oxygen saturation) and crying time were monitored by the researcher as indicators of fear and anxiety. The chi-square test, repeated measures analysis of variance, Friedman test, t test, the Mann-Whitney U test, Wilcoxon test, and the intraclass correlation test were used for data analysis.ResultsThere was no statistically significant difference in terms of fear and anxiety scores, physiological parameters, and crying time during the procedure between the children in the intervention and control group.DiscussionWe found that this method of toy distraction was not effective in reducing fear or anxiety during the intravenous catheter insertion procedure. Accordingly, we recommend that this distraction method be performed in different age groups and with larger samples in various painful and stressful practices in the future and that comparison be made with various distraction methods.     

Reducing Pain During Emergency Arterial Sampling Using Three Anesthetic Methods: A Randomized Controlled Clinical Trial

BackgroundTaking a sample of arterial blood is widely reported as a cause of significant pain.ObjectivesTo compare three anesthetic methods with standard practice (no anesthesia) to establish which was the most effective in reducing pain caused by radial artery puncture in patients requiring an arterial blood gas test in the emergency department (ED).MethodsA randomized controlled trial was conducted to compare the effectiveness between anesthetic cream, cryoanalgesia, and subcutaneous mepivacaine in reducing pain caused by radial artery puncture in ED patients.ResultsAfter comparing perceived pain during arterial puncture, the lowest median score was obtained in the mepivacaine group (1 interquartile range 0.6–1.3) and the highest median score in the control group (5 interquartile range 4.0–7.0). When comparing the control group with the three intervention groups, the Kruskal-Wallis test showed that mepivacaine (p = 0.023) and cryoanalgesia (p = 0.012) were associated with significantly lower pain scores. The anesthetic cream (p = 0.861) intervention group did not produce a statistically significant median difference compared with the control group.ConclusionsThe results of this study encourage the use of anesthetic methods like cryoanalgesia or mepivacaine for their proven effectiveness in reducing or eliminating pain during arterial puncture.     

Prednisone for Emergency Department Low Back Pain: A Randomized Controlled Trial

Background

Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit.

Objective

To determine if a short course of oral corticosteroids benefits LBP ED patients.

Methods

Design: Randomized, double-blind, placebo-controlled trial. Setting: Suburban New Jersey ED with 80,000 annual visits. Participants: 18–55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. Protocol: At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0–3 scale (none, mild, moderate, severe) as well as functional status.

Results

The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0–3 scale (absolute difference 0.2, 95% confidence interval [CI] −0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%).

Conclusion

We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.     

Using Distraction to Reduce Reported Pain, Fear, and Behavioral Distress in Children and Adolescents: A Multisite Study

ISSUES AND PURPOSE. Distraction during painful procedures has been shown to be effective in previous studies, yet this simple intervention is not used routinely. This study examined the effectiveness and feasibility of distraction in reducing behavioral distress, pain, and fear during venipuncture or intravenous insertion.
DESIGN AND METHODS. A two-group randomized design with 384 children in 13 children's hospitals.
RESULTS. Age was a significant factor in observed behavioral distress, reports of fear, and self-reported pain. The use of a kaleidoscope, however, did not significantly reduce pain or distress during venipuncture or IV insertion.
PRACTICE IMPLICATIONS. Failure of the distraction intervention to reach statistical significance in this study is puzzling, given anecdotal reports of clinical efficacy. Methodological issues may have obscured actual differences between experimental and control groups.     

Intranasal Sufentanil Versus Intravenous Morphine for Acute Pain in the Emergency Department: A Randomized Pilot Trial

Background

Patients in the United States frequently seek medical attention in the emergency department (ED) to address their pain. The intranasal (i.n.) route provides a safe, effective, and painless alternative method of drug administration. Sufentanil is an inexpensive synthetic opioid with a high therapeutic index and rapid onset of action, making it an attractive agent for management of acute pain in the ED.

Reclining Chairs Reduce Pain from Gurneys in Older Emergency Department Patients: A Randomized Controlled Trial

Objectives: Pain related to the gurney is a frequent complaint of older emergency department (ED) patients. The authors hypothesized that these patients may have less pain and higher satisfaction if allowed to sit in a reclining hospital chair. Methods: A single‐blind, randomized controlled trial was performed. Patients 65 years old or older who were able to sit upright, transfer, and engage in normal conversation were eligible. Severely ill or cognitively impaired patients were excluded. Patients were randomized to either remain on the gurney or transfer to the chair after initial evaluation. Patients reported pain at arrival (t0), at one hour (t1), and at two hours (t2) using a 0–10 pain scale, and satisfaction at study completion on a 0–10 scale. The primary outcome was a decrease in pain between t0 and t1 or no pain at both t0 and t1. This outcome was analyzed using a 95% confidence interval for the difference between proportions; exclusion of zero was considered significant. Results: Sixty‐six patients in each group were enrolled. There was no difference in demographics between groups, but the chair patients were more likely to have pain at t0 than the gurney patients. More chair patients than gurney patients had a successful primary outcome (97% vs. 76%, 21% difference, 95% CI=10% to 32%). The mean satisfaction score was higher in the chair group than in the gurney group (8.1 vs. 6.0, 2.1 difference, 95% CI=1.4% to 2.8%). Conclusions: The simple modification of allowing older ED patients to sit in reclining chairs resulted in less pain and higher satisfaction.     

Blood Culture Accuracy: Discards From Central Venous Catheters in Pediatric Oncology Patients in the Emergency Department

Introduction

Lack of specific guidelines regarding collection of blood for culture from central venous catheters (CVCs) has led to inconsistencies in policies among hospitals. Currently, no specific professional or regulatory recommendations exist in relation to using, reinfusing, or discarding blood drawn from CVCs before drawing blood for a culture. Repeated wasting of blood may harm immunocompromised pediatric oncology patients. The purpose of this comparative study was to determine whether differences exist between blood cultures obtained from the first 5 mL of blood drawn from a CVC line when compared with the second 5 mL drawn.

Methods

During 2009-2011, 62 pediatric oncology patients with CVCs and orders for blood cultures to determine potential sepsis were enrolled during ED visits. Trained study nurses aseptically drew blood and injected the normally discarded first 5 mL and the second specimen (usual care) into separate culture bottles. Specimens were processed in the microbiology laboratory per hospital policy.

Results

Positive cultures were evaluated to assess agreement between specimen results and to determine that the identified pathogen was not a contaminant. Out of 186 blood culture pairs, 4.8% demonstrated positive results. In all positive-positive matches, the normal discard specimen contained the same organism as the usual care specimen. In 4 matches, the normally discarded specimen demonstrated notably earlier time to positivity (4 to 31 hours) compared with the usual care specimen, which resulted in earlier initiation of definitive antibiotics.

Discussion

These findings support the accuracy of the specimen that is normally discarded and suggest the need to reconsider its use for blood culture testing.     

Using Buzzy,Shotblocker, and Bubble Blowing in a Pediatric Emergency Department to Reduce the Pain and Fear Caused by Intramuscular Injection: A Randomized Controlled Trial

IntroductionProcedural pain in general, and intramuscular (IM) injection pain in particular, is one of the most distressing and painful health care experiences for children. Pharmacologic and nonpharmacologic methods are used as forms of pain control for children undergoing acute painful interventions in emergency departments.MethodsThis study was a prospective, randomized controlled trial. The sample consisted of children aged 5 to 10 years old who required IM injections. Children were placed in 4 subgroups through randomization, using a computer program: the Buzzy (MMJ Labs. Atlanta, GA) group (n = 40), the ShotBlocker (Bionix Development Corporation, Toledo, OH) group (n = 40), the bubble-blowing group (n = 40), and the control group (n = 40). Immediately before and after the injection, the children, their parents, and an observer were asked to evaluate the child’s level of fear. The Oucher scale was also employed by the observers, children, and parents immediately after the procedure to assess the level of pain in the children in each group.ResultsNo statistically significant difference was determined between the control and intervention groups in terms gender, age, previous pain experienced with injection, the parent who was with the child, the parent’s age. A significant difference was found between the intervention and control groups in terms of levels of pain and fear during IM injection. Pain and fear were notably less in the group of children receiving the Buzzy intervention.DiscussionThe Buzzy intervention should be used when children are undergoing IM injections to reduce their levels of pain and fear.     

Comparison of Valdecoxib and an Oxycodone–Acetaminophen Combination for Acute Musculoskeletal Pain in the Emergency Department: A Randomized Controlled Trial

Oral opioids are potent analgesics that are used to treat acute pain in the emergency department (ED). However, they are associated with adverse events such as sedation that may delay safe patient discharge. OBJECTIVE: To compare the safety and efficacy of a new cyclooxygenase-2 inhibitor, valdecoxib, with those of an oxycodone-acetaminophen combination in patients with acute musculoskeletal pain. METHODS: This was a double-blind, randomized controlled trial at an immediate care section of a suburban university-based ED with an annual census of 75,000. Adults with acute musculoskeletal pain without contraindications to the study medications were included. After recording their initial pain scores, patients were randomized to either oral valdecoxib 40 mg or oxycodone 10 mg with acetaminophen 650 mg. Pain scores were recorded at 30 and 60 minutes, and patients who requested additional pain relief were given an oral analgesic at the physician's discretion. Twenty-four-hour telephone follow-up was performed. The pain severity was recorded at 0, 30, and 60 minutes using a validated 100-mm visual analog scale marked "most" at the high end. The need for rescue medications and the occurrence of adverse events were determined. Study outcomes were compared with Student's t-test, repeated-measures analysis of variance (ANOVA), and chi(2) tests as appropriate. RESULTS: Fifty-one patients were randomized to valdecoxib (26) or oxycodone (25). Mean (+/- SD) age was 36 (+/- 14.7) years; 49% were women. Pain locations included extremities (49%), neck (29%), and back (22%). Baseline patient characteristics and pain severities were similar. There was no between-group difference in pain scores at 30 and 60 minutes. The changes in pain scores over time were also similar in the two study groups (repeated-measures ANOVA, p = 0.32). Patients treated with valdecoxib were less likely to experience sedation/dizziness (15% vs. 44%, p = 0.03) and to require rescue medications within the next 24 hours (44% vs. 74%, p = 0.04). CONCLUSIONS: Valdecoxib is as effective as an oxycodone-acetaminophen combination in treating ED patients with acute musculoskeletal pain at 30 minutes and less likely to cause sedation or the need for rescue analgesia over the next day.     

Intravenous Lidocaine for the Emergency Department Treatment of Acute Radicular Low Back Pain,a Randomized Controlled Trial

Background

Acute radicular back pain is a frequent complaint of patients presenting to the Emergency Department.

Study Objective

Determine the efficacy of intravenous lidocaine when compared to ketorolac for the treatment of acute radicular low back pain.

Methods

Randomized double-blind study of 41 patients aged 18–55 years presenting with acute radicular low back pain. Patients were randomized to receive either 100 mg lidocaine or 30 mg ketorolac intravenously over 2 min. A 100-mm visual analog scale (VAS) was used to assess pain at Time 0 (baseline), and 20, 40, and 60 minutes. Changes in [median] VAS scores were compared over time (within groups) by the signed-rank test and between groups by the rank-sum test. A 5-point Pain Relief Scale (PRS) was administered at the conclusion of the study (60 min) and again at 1 week by telephone follow-up; [median] scores were compared between groups by rank-sum.

Results

Forty-four patients were recruited; 41 completed the study (21 lidocaine, 20 ketorolac). Initial VAS scores were not significantly different between the lidocaine and ketorolac groups (83; 95% confidence interval [CI] 74–98 vs. 79; 95% CI 64–94; p = 0.278). Median VAS scores from baseline to 60 min significantly declined in both groups (lidocaine [8; 95% CI 0–23; p = 0.003]; ketorolac [14; 95% CI 0–28; p = 0.007]), with no significant difference in the degree of reduction between groups (p = 0.835). Rescue medication was required by 67% receiving lidocaine, compared to 50% receiving ketorolac. No significant change in PRS between groups was found at the conclusion or at the follow-up.

Conclusion

Intravenous lidocaine failed to clinically alleviate the pain associated with acute radicular low back pain.     

Laser-assisted Anesthesia Reduces the Pain of Venous Cannulation in Children and Adults: A Randomized Controlled Trial

Objectives: Application of topical anesthetics before intravenous (IV) cannulation is effective yet limited by delayed transdermal absorption. The authors evaluated a handheld laser device to enhance topical anesthetic absorption by ablating the stratum corneum, the major barrier to drug absorption through the skin. The hypothesis was that laser‐assisted anesthesia would reduce the pain of IV cannulation in emergency department (ED) patients. Methods: This was a blinded, randomized, controlled trial. ED patients aged 1 year and older requiring nonemergent IV cannulation were included. Patients were randomized to pretreatment of the skin with laser or sham laser, and standardized venous cannulation was performed on the dorsum of the patients' hands or antecubital fossa. In the experimental group, the area over the target vein was pretreated with a lightweight, portable Er:YAG unit, with a fluence of 3.5 J/cm², a pulse width of 600 microseconds, and a spot diameter of 6 mm. Lidocaine 4% cream was applied to the area immediately after laser application. Five minutes later, the cream was wiped off and a trained nurse inserted an IV catheter. In the control group, a sham laser and lidocaine were used. Pain of laser application and IV cannulation was recorded on age‐appropriate pain scales; presence of infection or abnormal pigmentation was determined at one week. Pain of cannulation was compared using parametric and nonparametric tests. Results: Sixty‐one patients were randomized to laser (30) and sham (31) pretreatment. Mean (± SD) age was 27 (± 21) years, 49% were female, and one half were children younger than 18 years. The mean pain of IV cannulation was significantly less (mean difference, 28.3 mm; 95% confidence interval = 17.9 to 38.7) in patients pretreated with the laser (10.0 mm; 95% confidence interval = 4.4 to 15.6) than with sham laser (38.3 mm; 95% confidence interval = 29.3 to 42.2). The difference in children was also significant. Application of the laser was painless in most patients. No patient developed infection or abnormal pigmentation. Conclusions: Pretreatment of the skin with a laser device followed by a five‐minute topical lidocaine 4% application reduces the pain of IV cannulation in ED adult and pediatric patients.     

Quality Improvement in the Emergency Department: A Project to Reduce Door-to-Electrocardiography Times for Patients Presenting With Chest Pain

IntroductionThe American Heart Association/American College of Cardiology guidelines recommend obtaining electrocardiography for patients who present to the emergency department with chest pain in less than 10 minutes of arrival. Reducing door-to-electrocardiography time is an important step in adhering to the recommended door-to-balloon times (≤ 90 minutes) for patients who present with ST-segment elevation myocardial infarction.MethodsBased on lean sigma principles, a protocol was implemented in an adult emergency department that included deferring nurse triage for patients with complaints of chest pain, chest tightness, and chest pressure and providing them with a red heart symbol as an indicator for clinical technicians to prioritize their electrocardiography order. Pre- and postintervention data were collected over a 12-month period.ResultsBefore the intervention, the mean door-to-electrocardiography time was 17 minutes for patients with chest pain (n = 893). After the intervention, the mean door-to-electrocardiography time for patients with chest pain significantly decreased to 7 minutes (n = 1,057) (t = 10.47, P ≤ 0.001). Initially, the percentage of compliance with door-to-electrocardiography standard of 10 minutes was 31% and improved to 83% after implementation of the new protocol.DiscussionImplementation of the optimized door-to-electrocardiography protocol decreased the time for obtaining diagnostics and improved compliance with the American Heart Association/American College of Cardiology guidelines, potentially decreasing door-to-balloon times for patients who presented with ST-segment elevation myocardial infarction.     

Active Shooter Training in the Emergency Department: A Safety Initiative

Problem

Active shooter incidents are becoming more common, and although they are still rare compared with other shooting sites, incidents have increased in health care facilities. Agencies such as the Federal Bureau of Investigation, The Joint Commission, and the Emergency Nurses Association have emphasized that an action plan and training are essential for hospital preparedness.