improving Pain mAnagement for childreN and young people attendeD by Ambulance (PANDA): A realist informed intervention development and feasibility study.

BACKGROUND: Each year in England over 430,000 children and young people (CYP) under 18-years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted.

Studies have shown that pre-hospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance.

Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain.

AIMS & OBJECTIVES: To develop and test an intervention to improve pre-hospital pain management for children and young people by exploring what interventions work, for whom, in what context and how.

METHODS: Utilising a realist approach and following the Medical Research Council guidelines for complex intervention development, a realist informed intervention development and feasibility study will be conducted. The intervention will be co-produced with a Young Persons Advisory Group (YPAG).

Work Package (WP)1: A realist review of existing interventions, quality improvement initiatives, guidelines and policies to improve pain management in CYP in the pre-hospital setting will help us understand context, mechanism and outcome configurations (CMOC) and will facilitate the development of an initial programme theory.

WP2: We will conduct a realist evaluation involving a multiple case study (WP2a) and a consensus workshop (WP2b).

WP2a will use interviews, diaries and arts-based methods with CYP, their parents/carers and ambulance clinicians to determine which interventions work for whom, the mechanisms (M) by which they work and in what context (C). We will also analyse clinical record data to incorporate outcome (O) measures such as pain score.

We will then develop a middle range programme theory.

WP2b will use the consensus workshop method to determine the practical delivery of the middle range programme theory; an intervention will be developed, mapped to the Capability, Opportunity, Motivation, Behaviour (COM-B) model. WP3: A cluster feasibility randomised controlled trial and process evaluation will be conducted.

Paramedics will be randomised 1:1 to receive the intervention or not (standard care). The intervention may, for example, include training/education, feedback or pain management prompts.

CYP and parents/carers will be approached after treatment for consent to use their routine data and follow up at 1 and 3 months to assess pain level, sleep disturbance and post-traumatic stress disorder rates.

Interviews will be conducted with paramedics, CYP and parents/carers to determine acceptability and understand the mechanisms by which the intervention works. TIMELINE FOR DELIVERY: 45 months.

ANTICIPATED IMPACT AND DISSEMINATION: Findings from this study will be presented at conferences, published in peer reviewed journals and promoted via social media. An executive summary of findings will be submitted to the Association of Ambulance Chief Executives.

The intervention will likely improve the quality of care CYP receive when attended by ambulance, specifically by reducing pain.