Hospitalized Children With Limited English Proficiency: The Strive to Improve Analgesia

Research has revealed that there are significant deficits in the assessment, communication, and treatment of pain in medicine.^1–4  Thus, the Joint Commission and American Academy of Pediatrics created consensus statements to set standards for pain treatment >20 years ago.^5,6  Despite the increased focus on analgesia, children continue to experience inadequately treated pain while hospitalized.^3,4  Specifically, pediatric racial and ethnic minorities have been shown to receive analgesia less often and experience higher pain scores. Emerging research in populations with limited English proficiency (LEP) has revealed continued deficits in adequately treated pain.^7–9  Given the importance of language and communication in pain assessment, pediatric populations with LEP are at risk for significant inequities in care.

In this month’s Hospital Pediatrics, Payson et al¹⁰  examined inequities in pain assessment and management in hospitalized children with LEP as assessed by self-reported pain prevalence and intensity as well as nurse-documented pain assessments and analgesia. They conducted a prospective, cross-sectional study consisting of in-person surveys and electronic medical record review in a Southeastern freestanding children’s hospital. The patient population had a high degree of non-English language usage at home with ∼75% of the population in the county speaking another language. Access to 24-hour phone interpreter services was provided to hospitalized families with LEP. In-person interviews of 155 parent–child dyads were conducted on 4 nonconsecutive days over a 1-month period. Patients aged 0 to 21 years admitted to the medical and surgical wards for at least 12 hours were eligible for the study. Patients were interviewed directly if they were >5 years old. EMR data were then used to obtain additional demographic and clinical data. The chosen a priori outcome of the study was a difference of ≥3 points on the pain scale between patient-reported and nurse-documented worst pain scores. Interviews were conducted with 155 parent–child dyads with a 96% response rate. Children made up 50% of the interviewees (as compared with using a parental proxy) with a median patient age of 8 years; 64% of patients spoke English as their preferred language. Patients with LEP were more likely to be younger, female, Hispanic, use parental proxies, and have government insurance. This study revealed continued disparities in pain assessment and management for patients with LEP. Only 39% of patients with LEP had their pain exclusively assessed by nursing in their preferred language. Only 60% of patients with LEP received analgesia at the time of their worst pain compared with 82% of English proficient children. English proficient patients were also more likely to receive opioids as compared with patients with LEP (22% vs 9%, respectively). Both differences were statistically significant in this small cohort. There was a significant difference between nurse- and self-reported pain scores comparing LEP and English proficient patients (82% vs 55%, respectively). The unadjusted odds ratio was 3.68 (95% confidence interval: 1.39–11.03) of having a discrepant pain score when comparing patients with LEP with English proficient patients. These findings remained significant when adjusting for age, sex, and survey respondent (ie, child or parental proxy), (adjusted odds ratio = 3.23 [95% confidence interval: 1.13–10.31]).

Despite the many strengths of the study design and the substantial importance of the authors’ findings of inequity in pediatric pain assessment and management, there are some limitations. One limitation, as pointed out by the authors, includes limited generalizability as this was conducted at a single center institution. However, we also wonder why the authors chose to conduct this study over a short span of a month, with survey collection only occurring on 4 days out of this month. No power analysis was conducted to show that adequate sample size was reached, although the authors were able to show significant findings. Their findings should also be put into context; patients who were English proficient were significantly more likely to be older, illustrating a common American narrative, where children of immigrant parents often interpret for their parents. Although the median age of patients who were English proficient was 11 years of age, the median age of patients with LEP was 3 years of age, suggesting that a large percentage of patients with LEP may have been infants or not fully verbal. It may be more difficult, even for parental proxies, to accurately report an infant or nonverbal child’s pain. When comparing self-reported worst pain scores between groups, the median worst mean pain score was higher in patients with LEP, with the P value approaching significance (P = .08). It is unclear whether a larger sample size may have revealed differences in worst mean pain scores, and whether this may be due to difficulty interpreting pain in nonverbal patients. It is also unclear whether the timing of the patient’s worst pain coincided with nursing pain assessment, which may further cloud these findings. Although the authors performed an excellent exploration of pain assessment and management in patients with LEP, we hope that future studies may be able to address these limitations by collecting a larger sample, limiting the cohort to older patients who can reliably self-report pain, and ensuring that self-reported pain and nursing pain assessments occur at the same time.

This study is in line with previous research examining pain management in patients with LEP. Payson and colleagues’ main findings were that children with LEP were less likely to receive pain assessments in their preferred language, received less analgesia when experiencing their worst pain, and more often experienced a discrepant pain score when compared with nursing assessments.¹⁰  Previous work examining pain management in pediatric patients with LEP has highlighted that this population is at risk of receiving fewer pain assessments, delayed analgesia, fewer opioids, and having higher documented scores before receiving analgesia.^7–9  This study further supports previous findings. Regarding discrepant nursing scores, previous research has revealed lower nurse-reported pain scores for hospitalized pediatric patients when directly compared with the patient’s and/or parents’ experience via surveys.^3,11  However, there were little data regarding the association of language with discrepant nursing pain assessments. A major strength of this study is that it included a larger number of child respondents (50%) when compared with past studies and directly examined the impact of English proficiency with discrepant reports of pain. This study is also unique in that it was able to capture differences in language/interpreter use by nursing when assessing pain. They found that all English proficient participants had their pain assessed in their preferred language compared with only 34% of patients with LEP. Increased interpreter use has been associated with more equitable analgesia administration in hospitalized pediatric patients as well as improved patient-reported pain control.^7,12  Findings from this study could be used to further direct actionable interventions to reduce the inequities in pain management.

Hospital-based physicians have significant opportunities to reduce inequities in pain management because they often care for patients with pain after procedures, or with pain due to acute illness. Payson and colleagues further confirmed that disparities in pain management continue to be prevalent in pediatrics and, particularly, patients with LEP.^{1–4,7–10,13,14}  Hospital-based physicians can try to decrease these disparities by always using an interpreter when assessing pain in patients with LEP, and role-modeling this behavior to ensure trainees and medical staff also always use an interpreter when assessing pain in patients with LEP. Ensuring interpreter use whenever assessing pain in patients with LEP would be an excellent quality improvement project for a hospital-based physician or trainee. Physician awareness of inequities experienced by patients with LEP and ensuring that the medical team responds appropriately to self-reported pain from patients with LEP may also improve pain management in patients with LEP. Hospital-based physicians must also continue to ensure that all patients, including patients with LEP, are fully aware of all pain options on hospital admission, including medications that may only be available on a pro re nata basis. We should also continue to empower patients with LEP and their families to feel comfortable asking for an interpreter at any time. Finally, hospital-based physicians have been at the forefront of improving care for all hospitalized children. Future studies should focus on expanding our understanding of the pain experience directly from hospitalized children rather than relying on parental proxies, and work toward identifying additional interventions to reduce pain inequity in hospitalized children with LEP.