Georgie Nicholls

Background Prehospital pain management in children and young people (CYP) is a top research priority in paediatric emergency medicine. Approximately 90,000 CYP under 18 years of age are transported to hospital by ambulance each year for conditions associated with acute pain in England. Approximately half of the children suffering from acute pain do not receive analgesics from paramedics, and approximately 60% do not experience a meaningful reduction in their pain severity. The aim of these studies is to explore the experiences of key stakeholders, refine our programme theory, and prioritise candidate intervention components to address the gaps in care. Methods A realist evaluation using a multiple case study approach following the RAMESIS II guidance and consensus workshops using the modified nominal group technique will be performed. The realist evaluation will collect qualitative data (interviews, diaries, electronic messaging, arts-based materials) from CYP aged 4–17 years who have experienced acute pain and needed an ambulance in the previous 12 months, parents and carers, and ambulance clinicians. Recruitment will occur across England within three NHS ambulance services, two NHS children’s emergency departments, and via social media. We will also collect routine quantitative clinical record data from two NHS ambulance services. We will use a realist logic of analysis to code the data into conceptual buckets, develop context-mechanism-outcome configurations, and refine the programme theory developed from a previous realist review. Two consensus workshops will be held: one for CYP aged 7–17 years, parents and carers, public representatives, and members of the Young Persons Advisory Group, and one for ambulance clinicians, quality leads, and educators. Workshop attendees will review the study findings and candidate intervention components, vote on their importance, and review voting results. High-priority intervention components will be considered for incorporation into an intervention.

Background Prehospital pain management in children and young people (CYP) is a top research priority in paediatric emergency medicine. Approximately 90,000 CYP under 18 years of age are transported to hospital by ambulance each year for conditions associated with acute pain in England. Approximately half of the children suffering from acute pain do not receive analgesics from paramedics, and approximately 60% do not experience a meaningful reduction in their pain severity. The aim of these studies is to explore the experiences of key stakeholders, refine our programme theory, and prioritise candidate intervention components to address the gaps in care. Methods A realist evaluation using a multiple case study approach following the RAMESIS II guidance and consensus workshops using the modified nominal group technique will be performed. The realist evaluation will collect qualitative data (interviews, diaries, electronic messaging, arts-based materials) from CYP aged 4–17 years who have experienced acute pain and needed an ambulance in the previous 12 months, parents and carers, and ambulance clinicians. Recruitment will occur across England within three NHS ambulance services, two NHS children’s emergency departments, and via social media. We will also collect routine quantitative clinical record data from two NHS ambulance services. We will use a realist logic of analysis to code the data into conceptual buckets, develop context-mechanism-outcome configurations, and refine the programme theory developed from a previous realist review. Two consensus workshops will be held: one for CYP aged 8–17 years, parents and carers, public representatives, and members of the Young Persons Advisory Group, and one for ambulance clinicians, quality leads, and educators. Workshop attendees will review the study findings and candidate intervention components, vote on their importance, and review voting results. High-priority intervention components will be considered for incorporation into an intervention.

Background Prehospital pain management in children and young people (CYP) is a top research priority in paediatric emergency medicine. Approximately 90,000 CYP under 18 years of age are transported to hospital by ambulance each year for conditions associated with acute pain in England. Approximately half of the children suffering from acute pain do not receive analgesics from paramedics, and approximately 60% do not experience a meaningful reduction in their pain severity. The aim of these studies is to explore the experiences of key stakeholders, refine our programme theory, and prioritise candidate intervention components to address the gaps in care. Methods A realist evaluation using a multiple case study approach following the RAMESIS II guidance and consensus workshops using the modified nominal group technique will be performed. The realist evaluation will collect qualitative data (interviews, diaries, electronic messaging, arts-based materials) from CYP aged 4 – 17 years who have experienced acute pain and needed an ambulance in the previous 12 months, parents and carers, and ambulance clinicians. Recruitment will occur across England within three NHS ambulance services, two NHS children’s emergency departments, and via social media. We will also collect routine quantitative clinical record data from two NHS ambulance services. We will use a realist logic of analysis to code the data into conceptual buckets, develop context-mechanism-outcome configurations, and refine the programme theory developed from a previous realist review. Two consensus workshops will be held: one for CYP aged 8-17 years, parents and carers, public representatives, and members of the Young Persons Advisory Group, and one for ambulance clinicians, quality leads, and educators. Workshop attendees will review the study findings and candidate intervention components, vote on their importance, and review voting results. High-priority intervention components will be considered for incorporation into an intervention.

Acute pain management in children and young people (CYP) attended by ambulance services is a significant challenge due to the complex nature of pain, the variation of approach needed across the age range, and the unpredictability of the environment. We aimed to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. A realist review was conducted and reported in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. We developed an initial programme theory (PT) using key stakeholder input, searched the major bibliographic databases MEDLINE, CINAHL Complete and PsycINFO, and other sources from January 2000 to February 2024, screened and assessed relevance and rigour in duplicate, and performed synthesis and programme theory refinement. We developed an initial PT that focussed on the preparedness of staff and the expectations of CYP and parents/carers, along with key outcomes such as pain score severity, fear and anxiety. The subsequent search strategy yielded 1503 documents, of which 95 were included, representing empirical research articles, reviews, theses, book chapters and clinical guidelines. The initial PT was tested and refined throughout the synthesis to produce a PT underpinned by 34 context-mechanism-outcome configurations. The PT portrayed positive (e.g. presence of parents, focussed education and training, building trust) and negative (e.g. misinformation, fear and anxiety, long-term consequences) effects on prehospital acute pain management for CYP. This PT was mapped to the Behaviour Change Wheel to provide a clinically relevant behaviour change model for improvement. This realist review has provided a clinically focussed model to guide the improvement of prehospital acute pain management in children and young people attended by ambulance. The programme theory lays a foundation on which future empirical testing can be conducted to effect behaviour change in practice. Registration: CRD42024505978.

Background Each year in England, 450,000 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 prehospital 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. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. Methods A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT): develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening: conduct a thorough search of relevant research databases and other literature sources and perform screening in duplicate; 3) Relevance and rigour assessment: assess documents for relevance and rigour in duplicate; 4) Extracting and organising data: code relevant data into conceptual “buckets” using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement: utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual “buckets”, test and refine the IPT into a realist PT. Conclusion The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation. Registration PROSPERO Registration: CRD42024505978

Background Each year in England, 450,000 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 prehospital 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. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. Methods A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT): develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening: conduct a thorough search of relevant research databases and other literature sources and perform screening in duplicate; 3) Relevance and rigour assessment: assess documents for relevance and rigour in duplicate; 4) Extracting and organising data: code relevant data into conceptual “buckets” using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement: utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual “buckets”, test and refine the IPT into a realist PT. Conclusion The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation. Registration PROSPERO Registration: CRD42024505978

Background Each year in England, 450,000 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 prehospital 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. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. Methods A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT) – develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening – conduct a thorough search of relevant research databases and grey literature sources and perform screening in duplicate; 3) Document selection – assess documents for relevance and rigour in duplicate; 4) Extracting and organising data – code relevant data into conceptual “buckets” using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement – utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual “buckets”, test and refine the IPT into a realist PT. Conclusion The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation. Registration PROSPERO Registration: CRD42024505978