O1023: Use of Home Nonpharmacologic Interventions for Long Bone Fracture Pain After Emergency Department Discharge

Background: Nonpharmacologic interventions (ice, elevation, distraction and other techniques) are recommended for the treatment of acute pain after emergency department (ED) discharge. However, the frequency of use and use in relation to analgesics have not been investigated.

Objectives: For home nonpharmacologic interventions used after ED discharge, 1) determine the types/duration of use, 2) describe the relationship with analgesics, 3) identify variables associated with use.

Methods: This was a secondary analysis of the IMPROVE study, a multi-site prospective observational cohort study of children 4-17 years discharged with an isolated long bone fracture between 2019-2021. Parents reported daily about nonpharmacologic and analgesic use for pain via text. Demographic and injury data were abstracted from a linked electronic health record (PECARN) registry or provided by the parent/guardian via a text. Univariable Firth’s logistic regression with multiple imputation was used to identify characteristics associated with nonpharmacologic use.

Results: 1,819 children were included, ages 4- < 8 years (38%), 8- < 11 years (25%), 11- < 14 years (24%) and 14- < 18 years (13%). Most were male (62%), had an upper extremity fracture (90%). Many had a reduced fracture (47%) and reported moderate/severe pain at discharge (46%).

96% used nonpharmacologic interventions during the first week for a median of 6 days (3, 7 IQR). Distraction (87%) and elevation (85%) were the most frequently and consistently used nonpharmacologic interventions, while ice (42%) and other nonpharmacologic interventions (31%) were also used (Figure 1).

Analgesia was used in combination with nonpharmacologic methods in 92% during the first week for a median of 3 days (2, 6 IQR); 3% used only analgesics. From day 1 to 7, the proportion using only nonpharmacologic interventions increased from 9% to 27% while the proportion using both nonpharmacologic interventions and analgesics decreased from 83% to 27% (Figure 2). By day 7, 36% were using neither a nonpharmacologic nor an analgesic.

Children ages 11- < 14 had increased odds of nonpharmacologic use in the first week compared to 4- < 8 years (3.7 OR 95% CI (1.4, 9.8)). Children with moderate/severe pain at discharge from the ED were also more likely to have nonpharmacologic use than those with none/mild pain (2.1 OR 95% CI (1.1, 3.9)). Home analgesic use on any particular day was predictive of any nonpharmacologic use (e.g., Day 1 analgesic use (yes vs. no) had 3.9 OR 95% CI (2.2, 7.1)). Other patient characteristics/injury variables were not associated with increased nonpharmacologic use.

Conclusion: After ED discharge, children with an isolated long bone fracture frequently use nonpharmacologic interventions, including distraction and elevation, for a longer duration than analgesics are used. Patient and fracture characteristics such as age and pain severity at discharge are also associated with increased use. Interventional studies to evaluate effectiveness are needed to optimize ED discharge recommendations.