Abstract
Introduction
Child life specialists (CLS) are professionals who help pediatric patients navigate illness and treatment in a hospital setting. To become certified, CLSs must graduate with a bachelor’s degree, complete appropriate prerequisite coursework, obtain 600 h of clinical work under an internship with a certified CLS, and pass a qualifying exam. 1 At the institution evaluated in this study, CLSs do not work nights, weekends, or holidays. Larger hospitals tend to provide CLS coverage around the clock.
Hospitalized children have been noted to undergo on average 6.3 painful procedures a day. 2 A CLS’s role on the health care team is especially valuable when it comes to managing patient anxiety and distress about medical procedures. Their ability to provide procedural preparation and support through interventions such as medical play and distraction can significantly decrease perceived pain and anxiety in pediatric patients.3-5 Given their role in managing pain in non-pharmacological ways, there is reason to believe CLS intervention may reduce the need for opioid administration in pediatric trauma patients coping with injury and treatment.
Though previous studies have examined a link between CLS intervention and reduced patient pain, no study to our knowledge has investigated the direct role timing of CLS intervention plays in the reduction of total opioids. The study compares patients who received a CLS visit to those who did not receive CLS intervention to determine if CLSs played an important role in opioid reduction. This study also attempts to determine if there is a correlation between the time it takes for a pediatric trauma patient to receive a visit from a CLS and the amount of opioids administered to the patient. This study hypothesizes that patients seen earlier by a CLS will have lower total opioids.
Methods
This IRB-approved, retrospective study included 803 observations from trauma patients ages 0 to 17, obtained between October 2020 and October 2022. Patients in the study were identified in the registry and included all activated patients. Only patients with missing data or those on narcotic drips were excluded. The data set was constructed by transcribing chart data from Epic Care from a state-designated pediatric general hospital with a PICU. The main medication class reviewed was opioids, which were normalized to milligrams of morphine and morphine equivalents (MEQs). A standardized formulation spreadsheet provided by the pediatric hospital’s pharmacy was used to calculate MEQs. Intravenous fentanyl (Sublimaze®) was not listed on the pharmacy’s spreadsheet, so its MEQs were taken from the Sublimaze® factsheet.
Opioid prescribing was managed by pediatric surgeons, hospitalists, and specialists. Opioid dosing was based on weight. No changes in pain management and opioid prescribing protocols were put in place during the study period. Efforts are always made to minimize opioid usage among the pediatric patient population at this institution.
Chi-square test of independence was used to evaluate the difference in the percentage of patients who received pain medication between three different groups: patients who did not receive a CLS visit, those who received CLS intervention within 6 h (CLS <6 h), and those who received a CLS visit after 6 h (CLS >6 h). Mann-Whitney U test was used to observe the medians of age, total opioids (mg), MEQ/kg, MEQ/kg/length of stay (LOS), and injury severity score (ISS) between the three groups. Due to the limited hours that CLSs work, we felt that the 6-hour period best represented capturing patients who came in while they were on shift. Time to CLS intervention was determined based on time of admission. Chi-square analysis was used to analyze the association between CLSs, gender, and discharge destination. Finally, linear and multivariate linear regression were run to determine the effect of time to CLS and the presence of CLSs on total opioids along age, ISS, and HLOS. JASP version 0.18.2 was used for the analyses.
Results
During the study period, 803 patients met the inclusion criteria. Child life specialists saw 274 (33.8%) of these patients. Chi-square analysis showed that a significantly higher proportion of females (38.6%) than males (31.1%) were seen by a CLS (P = .031). A significantly higher proportion of the patients seen by CLS received pain medication compared to those who were not seen by CLS (81.4% vs 62.8%, OR = 2.595, 95% CI [1.825-3.688], P < .001). Child life specialist intervention did not reveal any significant association with discharge destination. Both groups were largely discharged home, including 92.6% of patients seen by CLSs and 93.3% of patients not seen by CLSs.
Descriptive Statistics of Pediatric Patients Who Saw CLS Versus Patients Who did Not Receive CLS
mg, milligrams; IQR, interquartile range.
Descriptive Statistics of Pediatric Patients That Received CLS <6 h Versus Patients That Received CLS >6 h
mg, milligrams; IQR, interquartile range.
Regression Analysis Showing the Effect of Time to CLS on Total Opioids
Discussion
The study examined the impact of CLSs on pediatric trauma patients, considering various demographic and clinical factors. Patients who received CLS intervention, especially those who received CLS <6 h, were significantly younger on average compared to those who did not. This finding suggests that CLSs may be more commonly needed for younger patients, possibly due to their unique needs for emotional support and coping strategies during medical procedures. An analysis of gender distribution revealed that females were more likely to receive CLS intervention compared to males. The CLSs at the studied institution do not have criteria that they use to prioritize which patients they see. Current standard work is at the discretion of CLSs as to which patients they see and in which order. These results suggest that this study’s CLSs prioritize seeing younger, female patients first. It is important to note, however, that CLSs were more likely to see patients who had higher ISS and required more total opioids and MEQ/kg during their stay, suggesting that they did prioritize seeing more injured patients. We identify this lack of standard work as to who gets seen and seen first as a limitation of our study but also see it as an opportunity to improve patient outcomes at our institution. The data from this study supports the need for a standardized protocol to direct CLSs to see the patients who would most benefit from their services first.
The regression analyses further explored the impact of CLSs on opioid administration, considering demographic and clinical covariates. Unsurprisingly, age and ISS emerged as significant predictors of opioid totals. Older patients usually require higher doses to manage their pain. More injured patients typically experience more pain. Since CLSs cannot see all patients, this data can help CLSs create a triage tool to determine which patients to see first. As noted earlier, no current tool exists at our institution.
Most notably in this study, pediatric trauma patients received less total opioids, less MEQ/kg, and less MEQ/kg/LOS when they were seen by a CLS <6 h compared to those that were seen by a CLS >6 h. This highlights the key role that timing plays in reducing patient need for pain relief. These patients did have a lower average median ISS, indicating less severe injuries, but ISS is a retrospectively determined score that CLSs would not know when they are deciding which patients to see. Another explanation for this is that the more injured patients were not stable enough to be seen by a CLS within the first 6 h after ED arrival. Given their staffing hours, some of the patients seen after 6 h were likely overnight admissions, who came to the hospital when CLSs were off-duty. A future study might compare opioid totals during periods of CLS working hours and off-duty hours to determine better how crucial early CLS intervention is to decreasing pediatric patient opioid totals.
This impact of CLSs on opioid totals can be further validated by the discovery that each minute without an initial visit from a CLS increases the patient’s opioid total by 0.015 mg. These findings parallel previous studies that show reduced pediatric pain with CLS intervention.3-5 One study, in particular, saw a significant reduction in pediatric opioid use with lower extremity trauma after a consult from a CLS. 6 These findings underscore the potential of CLS interventions to complement pharmacological approaches, reducing reliance on opioid analgesics and mitigating associated risks of dependency or adverse effects. Further exploration into the mechanisms underlying these trends is warranted to optimize pain management protocols and enhance patient outcomes.
Given these statistics, broadening CLS coverage could benefit pediatric trauma patients at the studied institution, but this expansion proves more difficult than it sounds. Despite their important role in helping children manage the stressful environment of the hospital, CLSs across the nation face burnout, a lack of funding, and understaffing. 7 Many CLSs feel that they are undervalued and their role on the health care team is underappreciated by hospital administrators. 7 Child life programs tend to rely on grant funding, which hinders their ability to work to their full potential and restricts CLS salaries. There is a nationwide shortage of CLSs due to a lack of internships, which are required for CLSs to become certified and practice. 8 People who are interested in a CLS career may not be able to obtain the internship needed to do so. Inconsistent or limited staffing can make it difficult to assess the value and impact of CLSs, which is why studies such as this one are important.
Limitations of the study include those of a single-institution, retrospective study. Further research is needed to explore the nuanced impact of CLSs on patient care and outcomes, considering the complex interplay of demographic, clinical, and psychosocial factors. A multicenter, prospective study with a larger sample size would allow for subanalyses that focus on the differences in benefits of CLSs among pediatric subspecialties, such as oncology or burn units. They might also compare the impact of CLS intervention on different injury types, such as blunt versus penetrating or operative versus nonoperative. Future studies might also put more focus on the psychological aspects of CLS intervention, such as patient and family satisfaction and long-term psychological benefits, in addition to more objective measurements of opioids received. More research is also needed to advocate on behalf of CLSs and their essential role on the pediatric health care team to increase their funding and number of internships.
In conclusion, the study provides insights into the association between CLSs and various clinical outcomes in pediatric trauma patients. Patients who are seen by a CLS soon after admission receive fewer total opioids at a rate of 0.015 mg less per minute. Though previous studies have examined a link between CLS intervention and reduced patient pain, no study to our knowledge has investigated the direct role timing of CLS intervention plays in the reduction of total opioids. Child life specialists at the studied institution had the opportunity to work with only one-third of this study’s patient population due to consistent understaffing as a result of the nationwide shortage of CLSs. This study advocates for the value of CLSs on pediatric trauma patient outcomes and advocates for an improvement to the systemic issues they face.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.