Clinically significant changes in acute pain in a pediatric ED using the Color Analog Scale

doi:10.1016/j.ajem.2006.12.010

The American Journal of Emergency Medicine

Volume 25, Issue 7, September 2007, Pages 739-742

https://doi.org/10.1016/j.ajem.2006.12.010 Get rights and content

Abstract

Objective

The purpose of this study is to quantify, using the Color Analog Scale (CAS), the degree of change in pain severity required to achieve a clinically significant improvement in pain.

Methods

A prospective descriptive study, using convenience sampling of children aged 5 and 12 years presenting to a pediatric emergency department (ED) with acute pain, was done. Children were asked to mark their pain severity on a previously validated CAS. After a pain intervention, the child was again asked to mark their pain intensity on the CAS and asked to describe the relative change in their pain. The main outcome measure was to quantify the smallest change required for the child to state that their pain was improved.

Results

One hundred twenty-six children with a mean age of 8.6 years (SD, 2.8 years) were enrolled. Males accounted for 56%. Pain was traumatic in 47.6% and nontraumatic in 52.4%. Of the 126 pain comparisons made, 28 children described their pain as “the same” and had a mean change in score of −0.10 cm (95% confidence interval [CI], −2.27 to 2.07 cm). Pain was judged to be a “little less” in 58 children, and the CAS score changed by a mean of −2.4 cm (95% CI, −3.15 to −1.72 cm). In the 29 children who judged their pain to be “much less,” the CAS score decreased by a mean of −5.4 cm (95% CI, −6.50 to −4.40).

Conclusion

A decrease on the CAS pain scale of 2.4 cm (95% CI, 2.95–1.92) is a clinically significant change in pain for children aged 5 to 12 years with acute pain. The CAS is a valuable tool in assessing responses to pain interventions.

Introduction

The assessment and management of pain, especially in the emergency department (ED), is extremely important. The evaluation and treatment of pain among children is becoming an increasingly important aspect of emergency care. In 2001, The Joint Commission on Accreditation of Health Care Organizations mandated the assessment and documentation of pain for all health care encounters [1]. There have been numerous reports of the inadequacy of pain recognition and relief. Recently, Drendel et al [2] showed that only 44.5% of ED visits had documented pain scores, and this often leads to the undertreatment of pain in the ill or injured child.

Self-report is recognized as being the most effective method to measure pain, with children as young as 3 years old being able to reliably self-report pain intensity [3]. Adequate assessment of pain requires a tool that has been validated in the setting in which it will be used. Another important aspect in pain evaluation is to determine the minimum clinically significant difference in pain experience, thus, allowing for documentation of pain relief after an intervention [4].

There are many pain scales available that can be used for pain assessments in a variety of settings. However, the Color Analog Scale (CAS) is one of the only pain scales that has been validated for use in children 5 years and older with acute pain who present to the ED [5]. In addition, the CAS is easy to use, inexpensive, and fast to administer, making it ideal in a busy ED setting. Only one previous study has examined what constitutes a significant change in pain scores using the CAS [6]. As such, reexamining the scale in a different population is warranted to ensure the generalizability of the results.

The objective of our study was to determine the clinically significant change in pain scale scores using the CAS in children between the ages of 5 and 12 years presenting to a pediatric ED.

Section snippets

Methods

We performed a prospective descriptive study using convenience sampling in the ED of an urban Children's hospital with an annual census of 55 000. The study was approved by the site's institutional review board. From September 2003 to July 2004, all children presenting to the ED aged 5 to 12 years were eligible for enrollment if they had a complaint of pain. They were enrolled when a research assistant was available, mainly between 1500 and 2400 hours, corresponding with the peak daily census.

Results

A total of 126 children with a mean age of 8.6 years (SD, 2.8 years; range, 5–12 years) were enrolled. Seventy-one (56.3%) were male; 65 (51.6%), Hispanic; 47 (37.3%), Caucasian; 4 (3.2%), African American; and 10 (7.9%) fell into the “others” category. Overall, on initial assessment, 24 (19%) children considered their pain to be mild, 48 (38%) considered their pain to be moderate, and 54 (43%) considered their pain to be severe by self-report.

Trauma was the etiology of the pain in 60 (47.6%)

Discussion

Several pain scales that can be used to assess changes in pain severity over time exist. A common one is the Visual Analogue Scale (VAS). Investigators in the adult population have quantified a reduction of 6.2 to 23 mm as clinically significant using the VAS [4], [8], [9], [10], [11], [12]. Powell et al [8] used a nonvalidated 100-mm nonhatched VAS in children between 8 and 15 years old and determined the minimum clinically significant change in VAS score to be 10 mm (95% CI, 7–12 mm).

The CAS

Conclusion

A decrease on the CAS pain scale of 2.4 cm constitutes a clinically significant change in pain for children aged 5 to 12 years with acute pain. The CAS is a valuable tool in assessing responses to pain interventions when limited to serial pain scores in individual patients (and not pain scores between different groups). In addition, these results are specific to the CAS, which is not necessarily exactly equivalent to other pain scales that use the centimeter measurement.

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: This study was supported by an unrestricted investigator-initiated study grant provided by McNeil Pharmaceuticals, Titusville, NJ.

: This study was presented as a poster presentation at the Pediatric Ambulatory Societies Annual Meeting, April 2005, in Washington, DC.

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Original ContributionsClinically significant changes in acute pain in a pediatric ED using the Color Analog Scale

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Comprehensive accreditation manual for hospitals

Pain assessment for pediatric patients in the emergency department

Pediatrics

Relief of pain and anxiety in pediatric patients in emergency medical systems

Pediatrics

Original Contributions
Clinically significant changes in acute pain in a pediatric ED using the Color Analog Scale