Discussion
acute pain, Pain, pain
Our investigation highlighted results that are partly disappointing and partly contradictory. In fact, the prevalence of M/SP was higher than in the previous audit, both during hospitalization and in the 24 h prior to the day set for the investigation. All this despite the hospital training initiatives addressed to physicians and nurses, such as the update of analgesic protocols and the organization of biannual continuing medical education (CME) courses on pain therapy. This is all the more true in light of the fact that there are periodic checks on the knowledge of the protocols by the healthcare workers, and these protocols involve a systematic measurement of pain.On the other hand, the daily prescription of pain therapy improved markedly in both hourly and as-needed indications. In addition, fewer children were prescribed no pain therapy than in the 2016 survey. However, this last positive data is accompanied by poor quality of the analgesic therapy even compared to the previous audit. In fact, the therapy administered resulted in a statistically significant under treatment of pain so that it was unable to alleviate much of the M/SP complained of by the patients.During hospitalization and in the 24 h before and during the interview, the prevalence of pain was lower in the DO than in the DS. This result probably reflects not only the difference in the characteristics of pain in the two departments (chronic rather than acute), but also a therapy which, although inadequate, was found to be better than that administered in the DS. In fact in the DO slightly better values in PMI, in the administration of hourly therapy and in the use of opioids were observed, and all patients with M/SP had a prescribed pain therapy. On the other hand, the use of as-needed therapy and multimodal analgesia was worse in DO.The determining factors of pain management practices are: (1) Factors related to health care professionals; (2) Organizational factors; (3) Factors relating to the parents; (4) Factors relating to the child [In Italy the context is completely different, so much so that a law (38/2010) was necessary to encourage the use of opioids and eliminate the excess of bureaucracy that weighed on the prescription of opioids [In this sense, the reduced use of opioids in our hospital is the expression of a cultural distortion on which unfortunately there is still a lot to work.It is necessary to dwell on what could be solutions to the problems highlighted in this study.We should certainly improve some aspects of pain assessment, but above all think of a different organization at least with regard to acute pain, and improve CME courses and information for parents and patients when possible. Facilitations for a correct pain management practice can be provided by a pain management service. At Ospedale Pediatrico Bambino Gesù IRCCS, pain management is currently ensured by ward doctors, assisted by a multidisciplinary commission for therapeutic standards and pain assessment and anesthesiologists are called only for the most difficult cases. Unfortunately this reality is widespread in much of the Italian territory, as demonstrated by Vittori et al. [The comparison of the results from the two departments showed that this model did not facilitate overcoming the knowledge gap. This is more evident in the DS than in the DO where, in consideration of the fact that patients have recently undergone surgery and that therefore a higher intensity of pain is expected, it would be necessary to change some aspects: (1) Establish an Acute Pain Therapy Service with dedicated staff and (2) bring the pain assessment to every 6 h instead of the current one every 8 h. The implementation of an acute pain service improve the postoperative care of children and adults, and since 2010 the Royal College of Anesthetists in the United Kingdom suggested that a member of the Acute Pain Service visit all the children undergoing major surgery and a nurse from the pain service visit the wards each day in order to support nurses giving care for children in pain [For all hospital health workers, in addition to the commitment to continuing education, it would be necessary to focus attention also on effective and safe use of drugs, especially opioids, alongside an intensification of psychological therapy, non-drug therapy and set up courses for parents and children [