Performance Evaluation of a Supervised Machine Learning Pain Classification Model Developed by Neonatal Nurses.

BACKGROUND: Early-life pain is associated with adverse neurodevelopmental consequences; and current pain assessment practices are discontinuous, inconsistent, and highly dependent on nurses' availability. Furthermore, facial expressions in commonly used pain assessment tools are not associated with brain-based evidence of pain. PURPOSE: To develop and validate a machine learning (ML) model to classify pain. METHODS: In this retrospective validation study, using a human-centered design for Embedded Machine Learning Solutions approach and the Neonatal Facial Coding System (NFCS), 6 experienced neonatal intensive care unit (NICU) nurses labeled data from randomly assigned iCOPEvid (infant Classification Of Pain Expression video) sequences of 49 neonates undergoing heel lance. NFCS is the only observational pain assessment tool associated with brain-based evidence of pain. A standard 70% training and 30% testing split of the data was used to train and test several ML models. NICU nurses' interrater reliability was evaluated, and NICU nurses' area under the receiver operating characteristic curve (AUC) was compared with the ML models' AUC. RESULTS: Nurses weighted mean interrater reliability was 68% (63%-79%) for NFCS tasks, 77.7% (74%-83%) for pain intensity, and 48.6% (15%-59%) for frame and 78.4% (64%-100%) for video pain classification, with AUC of 0.68. The best performing ML model had 97.7% precision, 98% accuracy, 98.5% recall, and AUC of 0.98. IMPLICATIONS FOR PRACTICE AND RESEARCH: The pain classification ML model AUC far exceeded that of NICU nurses for identifying neonatal pain. These findings will inform the development of a continuous, unbiased, brain-based, nurse-in-the-loop Pain Recognition Automated Monitoring System (PRAMS) for neonates and infants.

Application of a human-centered design for embedded machine learning model to develop data labeling software with nurses: Human-to-Artificial Intelligence (H2AI).

BACKGROUND: Nurses are essential for assessing and managing acute pain in hospitalized patients, especially those who are unable to self-report pain. Given their role and subject matter expertise (SME), nurses are also essential for the design and development of a supervised machine learning (ML) model for pain detection and clinical decision support software (CDSS) in a pain recognition automated monitoring system (PRAMS). Our first step for developing PRAMS with nurses was to create SME-friendly data labeling software. PURPOSE: To develop an intuitive and efficient data labeling software solution, Human-to-Artificial Intelligence (H2AI). METHOD: The Human-centered Design for Embedded Machine Learning Solutions (HCDe-MLS) model was used to engage nurses. In this paper, HCDe-MLS will be explained using H2AI and PRAMS as illustrative cases. FINDINGS: Using HCDe-MLS, H2AI was developed and facilitated labeling of 139 videos (mean = 29.83 min) with 3189 images labeled (mean = 75 s) by 6 nurses. OpenCV was used for video-to-image pre-processing; and MobileFaceNet was used for default landmark placement on images. H2AI randomly assigned videos to nurses for data labeling, tracked labelers' inter-rater reliability, and stored labeled data to train ML models. CONCLUSIONS: Nurses' engagement in CDSS development was critical for ensuring the end-product addressed nurses' priorities, reflected nurses' cognitive and decision-making processes, and garnered nurses' trust for technology adoption.

Debriefing After Critical Events Is Feasible and Associated With Increased Compassion Satisfaction in the Pediatric Intensive Care Unit.

BACKGROUND: Repeated exposure to death and dying increases health care professionals' risk for burnout and secondary traumatic stress. Pediatric critical care providers are at particularly high risk because the death and dying of children are associated with even greater psychological impact. LOCAL PROBLEM: A charge nurse in the pediatric intensive care unit identified a need for additional staff support after critical patient events. METHODS: The aim of this quality improvement project was to design and implement a debriefing process, the Rapid Review of Resuscitation, in a 40-bed, high-acuity pediatric intensive care unit at an urban children's hospital in the midwestern United States. A preintervention-postintervention survey used the Professional Quality of Life Scale, version 5, to evaluate staff members' compassion satisfaction, burnout, and secondary traumatic stress before and 1 year after implementation. The debriefing process was designed and implemented on the basis of interview data and literature review. RESULTS: Preimplementation (104 of 222 staff members [47%]) and postimplementation (72 of 184 staff members [39%]) survey responses were compared. Compassion satisfaction scores (mean [SD] T scores: preimplementation, 54.10 [7.52]; postimplementation, 56.71 [6.62]) were significantly higher (P = .02) 1 year after implementation. Burnout (P = .69) and secondary traumatic stress (P = .06) scores were not significantly different. After implementation, 74% of respondents reported that the debriefing process was "very helpful" or "somewhat helpful" after critical patient events. CONCLUSIONS: Compassion satisfaction improved and burnout and secondary traumatic stress did not change with implementation of the debriefing process after critical patient events.

Using Hospital Incident Command Systems to Respond to the Pediatric Mental and Behavioral Health Crisis of the COVID-19 Pandemic.

ABSTRACT: Hospital incident command systems (HICS) were implemented to expand mental and behavioral healthcare (MBHC) services during the COVID-19 pandemic. Data on patient census, nurse vacancies, staff injuries, and staff perceptions were analyzed to quantify issues and track progress toward HICS goals. Data, environment of care, staffing, staff support, staff education, and communication resources were developed. After HICS implementation, 84% of nurses reported confidence in providing care to youth with acute MBHC needs. Nurse leaders should consider HICS for addressing other crises.

Agreement of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) With NICU Nurses' Assessments.

BACKGROUND: Objective assessment tools should standardize and reflect nurses' expert assessments. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and the Neonatal Infant Pain Scale (NIPS) are valid measures of pain. The N-PASS also provides a sedation subscale. PURPOSE: The objective of this study was to determine N-PASS clinical validity and utility by evaluating agreement of N-PASS scores with bedside nurses' assessments of pain/agitation and sedation in a 64-bed tertiary neonatal intensive care unit. METHODS: Fifteen bedside nurses trained to use the N-PASS and the NIPS prospectively completed 202 pain/agitation and sedation assessments from a convenience sample of 88 infants, including chronically ventilated, medically fragile infants. N-PASS and NIPS scores were obtained simultaneously but independently of nurse investigators. Bedside nurses also made recommendations about infants' pain and sedation management. RESULTS: There was moderate agreement between N-PASS pain scores and nurses' recommendations (κ= 0.52), very strong agreement between N-PASS sedation scores and nurses' recommendations (κ= 0.99), and very strong associations between N-PASS pain and NIPS scores ( P < .001). Bedside nurse and independent investigator interrater reliability was good for N-PASS pain and NIPS scores (intraclass correlation coefficient [ICC] = 0.83, ICC = 0.85) and excellent for N-PASS sedation (ICC = 0.94). During 93% of assessments, bedside nurses reported that the N-PASS reflected the level of infant sedation well or very well. IMPLICATIONS FOR PRACTICE AND RESEARCH: The N-PASS provides an easy-to-use, valid, and reliable objective measure of pain and sedation that reflects nurses' assessments. Additional studies using the N-PASS are needed to verify results and the influence of the N-PASS on pain and sedation management for medically fragile infants with chronic medical conditions.

Variability in qualifications for principal investigator status in research studies by nurses: A call for clarification.

PURPOSE: To describe existing guidance for qualifications of principal investigator s (PI s) of human subjects research and explore how they are operationalized for pediatric nurse scientists and clinical nurses in children's hospitals. DESIGN AND METHODS: After reviewing federal regulations, accreditation guidelines, and the literature, a convenience sample of members of the National Pediatric Nurse Scientist Collaborative (NPNSC). Participants completed a 33-item survey that included questions about Institutional Review Board (IRB), guidelines, and policies for PI status at their affiliated children's hospitals. RESULTS: The survey was electronically disseminated to 179 members of NPNSC through the Collaborative's listserv. Of the 39 members who responded, 90% hold a PhD and 80% practice in a free-standing children's hospital, nearly all of which (93%) are recognized as Magnet® hospitals. While the majority of respondents indicated that nurse scientists and other nurses were allowed to be PIs of research studies, educational requirements for PI status varied, with 3% requiring a PhD, 15% a baccalaureate degree, and 10% a graduate degree. 54% of respondents reported there was no degree requirement for PI status; however15% reported that even doctorally prepared nurse scientists cannot serve as PIs of research studies at their affiliated children''s hospitals. CONCLUSIONS: The survey identified substantial variability in requirements for PI status and potential barriers to pediatric nurses conducting independent research as PIs at children's hospitals. PRACTICE IMPLICATIONS: Operationalizing existing guidance will expand inclusion of nurse scientist expertise in human subjects research.

Pain Quality After Pediatric Pectus Excavatum Repair.

BACKGROUND: Neuropathic pain medications are included in multimodal postoperative analgesic strategies, but quality of perioperative pain is rarely assessed. AIMS: The purpose of this study was to describe adolescents' pain experiences after thoracoscopic pectus excavatum repair (Nuss procedure) using the Adolescent Pediatric Pain Tool. DESIGN: This prospective descriptive longitudinal study was designed to test the hypothesis that pain quality descriptors reported are consistent with neuropathic pain. METHODS: A convenience sample of 23 adolescents aged 12 to 17 years from a single urban, university affiliated, nonprofit children's hospital consented to self-report pain using the Adolescent Pediatric Pain Tool before and during hospitalization, and up to 14 months after Nuss procedure. Visual analytic techniques were used to analyze reported pain intensity, location, and affective, evaluative, sensory, and temporal qualities. RESULTS: Postoperative pain quality, intensity, number of sites, and surface area decreased over time. Word clouds illustrated that neuropathic sensory and temporal pain quality descriptors increased in frequency 2 to 6 weeks after surgery and were the predominant descriptors 2 to 4 months after surgery. Dot matrix charts illustrated an inconsistent relationship of pain quality and intensity with pain surface area. CONCLUSIONS: Pain quality should be assessed with valid, reliable, and developmentally appropriate tools. Visual analytics help illustrate pain quality at single points in time and longitudinally and may be helpful in guiding postoperative pain treatment.

Nurses' management of children's acute postoperative pain: A theory of bureaucratic caring deductive study.

BACKGROUND: Few studies have examined the translation of nurses' knowledge of pain management into clinical practice or how nurses negotiated the bureaucracy of caring to treat patients' acute pain. PURPOSE: This study describes factors that influence pediatric nurses' actions in caring for hospitalized children's acute post-surgical pain. METHOD: Ray's Theory of Bureaucratic Caring provided the theoretical framework for this mixed methods study of ethnography and human factors engineering. Fourteen nurses were observed throughout their shifts (175.5 h) to elucidate humanistic and bureaucratic influences. FINDINGS: Of 105 pain assessments, nurses intervened with pharmacologic (n = 45) and biobehavioral (n = 13) interventions for pediatric patients' post-surgical pain in less than 11 min; and 25 assessments revealed patients did not have pain. Pain was assessed and no intervention was provided to 4 patients who were asleep, 5 patients who refused, 2 patients who had no ordered analgesics and 10 patients who were assessed prior to peak effectiveness of their prior analgesic. Overall pain was well-controlled. Of the 28 themes identified, the interplay of 6 categorized to the social/cultural humanistic, 7 political, and 6 technologic/physiological bureaucratic dimensions most strongly influenced pain care. DISCUSSION: To achieve optimal pain care outcomes, nurses' and parents' pain management knowledge was less influential for clinical practice translation than nurses' negotiation of other dimensions of bureaucratic caring.

Adolescents' Understanding of Opioid-Induced Euphoria Measures and Proposed Measurement Revisions.

Prescription opioid misuse is an unintended consequence of acute pain management. Opioid-induced euphoria (OIE) with first therapeutic opioid exposure may influence opioid misuse. OIE is not assessed in clinical care and self-report measures of OIE have not been validated in adolescents. We (1) determined adolescents' ability to understand existing self-reported OIE measures, (2) revised measures for better understanding by this population, and (3) established initial content validity of revised measures with adolescents. Using runner's euphoria to simulate OIE in Study 1, 29 adolescents' (14 males) understanding of the Drug Effects Questionnaire (DEQ-5), the Addiction Resource Center Inventory Morphine Benzedrine Group scale (ARCI-MBG), and the ARCI Lysergic Acid Diethylamide scale (ARCI-LSD) were tested. In Study 2, 29 additional adolescents (9 males) participated in a modified Delphi study with focus groups to revise survey items to improve understanding by peers. In Study 1, runners understood <40% of ARCI-MBG and ARCI-LSD statements. In Study 2, all but 7 survey items were revised. Revised measures of OIE for adolescents may help define at-risk OIE phenotypes and validate risk assessments using survey methodology. Additional studies are needed to validate the revised OIE self-report measures with opioid-naive adolescents receiving opioids to treat acute pain.

Use of Opioids and Nonopioid Analgesics to Treat Pediatric Postoperative Pain in the Emergency Department.

OBJECTIVES: The incidence, demographic characteristics, and treatment approaches for pediatric patients who present to the ED with a primary complaint of postoperative pain have not been well described. The purpose of this study was to describe opioid and nonopioid prescribing patterns for pediatric patients evaluated for postoperative pain in the Emergency Department (ED). METHODS: Pediatric Health Information System is an administrative database of encounter-level data from 48 children's hospitals. Emergency department visits for postoperative pain from January 2014 to September 2017 were analyzed. Visits were matched by the Pediatric Health Information System identifier to associate corresponding same site surgery encounters directly preceding ED visits. RESULTS: There were 7365 ED visits for acute postoperative pain, for which 4044 could be linked to corresponding surgical procedure. Eight-one percent of ED visits were within 7 days of surgery. Opioids were given at 1979 (49%) of visits, and nonopioids at 678 (17%) of visits. The most common surgeries preceding a postoperative pain ED visit were for tonsils and adenoids (48.5%). Age, sex, length of stay for both procedure and ED visits, procedure specialty, and the number of days between procedure discharge and admission to ED were associated with opioid administration during ED visits (P < 0.05). CONCLUSIONS: Pediatric patients treated in the ED for postoperative pain were often treated with opioid and nonopioid analgesics, with wide prescriber variability. Further research is warranted to help balance optimal pain management and safe prescribing practices.

Effectiveness and Dissemination of the Interprofessional Pediatric Pain PRN Curriculum.

INTRODUCTION: Cultural transformation is needed for health care to be sensitive to children's pain. The Pediatric Pain Practice Registered Nurses (PRN) Curriculum is the first free, open access, downloadable, interprofessional pain continuing education (IPPCE) curriculum developed to empower health care professionals to translate evidence-based pain care into clinical practice. To evaluate the curriculum and its experiential flipped-learning strategies, we used a mixed methods approach. METHODS: Interprofessional pediatric teams from eight health care systems evaluated the curriculum after attending Pediatric Pain PRN Courses in the Fall of 2017 (N = 90). Qualitative methods were used to evaluate the acceptability, feasibility, and utility of the curriculum and IPPCE strategies. Pain knowledge and attitudes were measured pre-IPPCE/post-IPPCE with the Pediatric Healthcare Provider's Knowledge & Attitude Survey Regarding Pain (PHPKAS). Web analytics were used to describe dissemination for the first year after the curriculum's webpage launch. RESULTS: Learners rated their achievement of course objectives as moderate-great. PHPKAS scores significantly increased (P < .0005); but significant differences in physician and nurse PHPKAS question responses pre-IPPCE/post-IPPCE were found. Within 2 years of the IPPCE, three health care systems were certified as Childkind Hospitals, five Pediatric Pain PRN Programs were established, and various practice changes and improved patient outcomes, such as decreased hospital lengths of stay and emergency department returns for pain, were realized. Curriculum dissemination was global. DISCUSSION: Results support the acceptability, effectiveness, feasibility, utility, and global dissemination of the curriculum and IPPCE strategies. More rigorous patient outcome data are needed; however, this study demonstrated the benefit of a free, open-access, downloadable, interprofessional health care provider continuing education curriculum.

Timing of Pegfilgrastim: Association with Febrile Neutropenia in a Pediatric Solid and CNS Tumor Population.

Background: While recommended timing of pegfilgrastim administration is ≥24 h after chemotherapy, patient barriers to next day administration, available adult evidence, and pharmacokinetic data have led to earlier administration in some pediatric patients with solid and central nervous system tumors. The purpose of this study was to compare patient outcomes by timing of pegfilgrastim after chemotherapy. Methods: A retrospective chart review examined timing of 932 pegfilgrastim administrations to 182 patients, 0-29 years of age. The primary outcome was febrile neutropenia (FN); the secondary outcome was neutropenic delays (ND) ≥7 days to next chemotherapy cycle. To account for multiple pegfilgrastim administrations per patient, a generalized mixed model was used with a logit link for the dichotomous outcomes (FN & ND), timing as the dichotomous independent variable, and random effect for patient. Results: FN occurred in 196 of 916 cycles (21.4%); and ND in 19 of 805 cycles (2.4%). The fixed effect of pegfilgrastim administration < or ≥24 h after chemotherapy was not significant, p = .50; however, earlier or later than 20 h was significant, p = .005. FN odds were significantly higher when pegfilgrastim was given <20 h (OR 1.78, 95% CI: 1.19-2.65) after chemotherapy, which may be attributable to differences in chemotherapy toxicity regardless of pegfilgrastim timing. Discussion: While attempts should be made to administer pegfilgrastim ≥24 h after chemotherapy, if barriers exist, modified timing based on individual patient characteristics should be considered. Prospective randomized trials are needed to identify lower risk patients for early pegfilgrastim administration.

Time from Pain Assessment to Pain Intervention.

OBJECTIVE: The purpose of this study was to describe factors that influence nurses' time from pain assessment to intervention for acute postsurgical pain. BACKGROUND: Nurses' time is a limited resource that must be optimized to manage patients' pain within budget constraints. Little is known about processes and activities nurses negotiate to manage pain. METHODS: Human factors engineering and ethnography were used to quantify factors influencing time from pain assessment to intervention. RESULTS: On the basis of 175.5 observation hours, nurses spent 11% of shifts (mean, 83 minutes) on pain care activities. Time from alert to intervention with PRN analgesics or biobehavioral strategies for 58 cases ranged from 0 to 48 minutes (mean, <11 minutes). Five factors influenced timeliness. CONCLUSIONS: Nurses most efficiently managed postsurgical pain by giving analgesics ordered PRN on a scheduled basis. Nurse leaders can empower prompt responses to patients' pain through delegation, process improvements, real-time monitoring, and prescriber engagement.

Over-The-Counter Analgesics: A Meta-Synthesis of Pain Self-Management in Adolescents.

BACKGROUND: The consumption prevalence of OTC medication ranges between 57% and 78% among adolescents in the United States of America; however, the reasons for self-medication with OTC analgesics have not been systematically examined. AIMS: The purpose of this meta-synthesis is to generate new knowledge and theoretical understanding of adolescents' use of over-the-counter (OTC) analgesics. DESIGN: Qualitative meta-ethnography using Noblit and Hare's (1988) approach. SETTINGS: PARTICIPANTS/SUBJECTS: METHODS: We identified qualitative studies in the CINAHL, PubMed, PsycINFO, and ProQuest Dissertation and Thesis databases that addressed OTC analgesic use in adolescents, were published between 2006 and 2018, and were written in English. Themes were extracted from studies meeting inclusion/exclusion criteria and a meta-ethnographic analysis was conducted. RESULTS: Seven studies met inclusion/exclusion criteria. Four themes were identified that described reasons for adolescent use of OTC analgesics for pain management: 1) survival instinct; 2) placebo for stress and anxiety control; 3) accessibility; and 4) consumer socialization. CONCLUSIONS: Findings suggest that OTC analgesic use is common among adolescents to treat pain and other non-medically-indicated conditions, such as stress and anxiety.

Children's Opioid Use at Home After Laparoscopic Appendectomy.

BACKGROUND: To combat the opioid epidemic, prescribers need accurate information about pediatric home opioid requirements to manage acute pain after surgery. Current opioid use estimates come from retrospective surveys; this study used medication adherence technology (eCAP) to track home opioid use. PURPOSE: To describe children's pain treatment at home after laparoscopic appendectomy, and to compare self-reported opioid analgesic use to eCAP data and counts of returned pills. DESIGN: Prospective exploratory and descriptive study METHODS: A convenience sample of 96 patients, 10-17 years of age, from a single urban nonprofit children's hospital consented to self-report pain treatment in 14-day diaries and use eCAP to monitor prescribed opioid use at home after laparoscopic appendectomy. RESULTS: Patients were prescribed 5-45 opioid-containing pills (mean ± standard deviation 15 ± 7.2). Of 749 opioid-containing pills prescribed to 49 patients who returned data, 689 pills were dispensed, 167.5 were used for the reason prescribed, 488 were returned to families for disposal, and 53.5 were missing. The majority of the 49 patients were opioid naïve (72%), Caucasian (64%), and male (56%), with a mean age of 14 years. Patients used 6.6 ± 6.3 opioid-containing pills by pill count and 5.6 ± 5.1 by self-report, a significant difference (p = .004). Unreported eCAP-enabled pill bottle openings typically occurred on weekends. CONCLUSION: Medication adherence technology (eCAP) is a more rigorous method than self-report to estimate opioid needs and detect early opioid misuse. Additional rigorously designed studies of postoperative opioid use are needed to guide opioid prescribing.

Children's Pain at Home After Laparoscopic Appendectomy.

BACKGROUND: Hospitalized children experience moderate-to-severe pain after laparoscopic appendectomy, but knowledge of children's pain experiences after discharge home is limited. Accurate pain assessments are needed to guide appropriate pain treatment. AIMS: To describe children's pain at home after laparoscopic appendectomy. DESIGN: Prospective exploratory and descriptive METHODS: A convenience sample of 100 patients, aged 10-17 years, who spoke or wrote in English or Spanish, volunteered to complete 14-day pain diaries at home after laparoscopic appendectomy. Visual analytic techniques were used to analyze patterns of pain experiences. RESULTS: Diaries were returned by 45 patients/parents, the majority of whom were White (64%), male (56%), adolescents (mean age 14 years) with no previous surgical history (70%), and whose appendix was inflamed (87%) but not perforated. More than 50% reported severe pain (4 or 5 on a 0-5 scale) on the first full day home after laparoscopic appendectomy. On day 7, 40% reported pain and on day 14, 16% were still reporting pain. Only rarely were pain scores not clinically significantly lower 1 hour after pain treatment, regardless of treatment type (e.g., nondrug, nonopioid, opioid). Reported pain intensity steadily decreased over time as did frequency of recorded pain scores. CONCLUSION: Adolescents experience severe pain at home after laparoscopic appendectomy and some experience pain for 7 to 14 days after hospital discharge. Visual analytics better represent the dynamics of pain experiences than measures of central tendency.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement.

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

ASPMN 2019 Position Statement: Pain Assessment in the Patient Unable to Self-Report.

Managing pain in those vulnerable populations who are unable to self-report or communicate is challenging due to difficulty recognizing pain presence and severity. As no valid and reliable objective measure of pain exists, the ASPMN supports assessment practice recommendations that gather relevant information to infer presence of pain and evaluate response to intervention. Nurses and other healthcare professionals must be advocates for those who are unable to speak for themselves regarding their pain experience.

Pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients.

OBJECTIVE: Identify demographic variables related to emergency department (ED) returns, and analgesic administration in the ED for postoperative pain after adenotonsillectomy (T&A). STUDY DESIGN: Pediatric Health Information System (PHIS) database analysis. METHODS: Forty-seven children's hospitals included in the PHIS database were queried for all ED visits within 30 days of surgery with a diagnosis of acute postoperative pain (n = 2459) from 2014 to 2015. The subset of postoperative T&A patients (n = 861) was further analyzed for variables associated with return, and for pain management strategies, specifically opioids, employed by the ED. RESULTS: Of the 2459 pediatric patients returning to the ED for acute postoperative pain, the largest subset included T&A patients (n = 861, 35%). Patients were seen an average of 4 days (SD 2.4) after their surgery. ED administration of opioids was not associated with gender, race, surgical diagnosis, or ethnicity. The rate of opioid administration by the ED increased with advancing age of the children analyzed (P = .01). The incidence was also higher for those with commercial versus Medicaid insurance carriers. A total of 204 (23.7%) patients received opioids while in the ED, 439 (51%) received both opioids and non-opioids, and only 51 (5.9%) received no pain medication. CONCLUSION: T&A patients make up the largest subset of patients returning to the ED for postoperative pain. A total of 74.7% of patients receive opioids, either alone or in combination with non-opioids, on return to the ED. ED opioid administration was associated with older age of the child and payer, but not with gender, race, surgical diagnosis, or ethnicity. LEVEL OF EVIDENCE: 4.

''As-Needed'' Range Orders for Opioid Analgesics in the Management of Pain: A Consensus Statement of the American Society for Pain Management Nursing and the American Pain Society.

Effective pain management requires careful titration of analgesics and evaluation of individual patient's responses to treatment using valid and reliable pain and pain relief assessment tools, and evidence-based patient monitoring for adverse treatment effects. A registered nurse, competent in pain assessment and analgesic administration, can safely interpret and implement properly written ''as-needed'' or ''PRN'' range orders for analgesic medications. The American Society for Pain Management Nursing (ASPMN) and the American Pain Society (APS) support safe medication practices and the appropriate use of PRN range orders for opioid analgesics in the management of pain.