Developing nursing interventions in Paediatric Emergence Delirium: a scoping review

Abstract

Background

Children who experience Emergence Delirium following an anaesthetic are at an increased risk of injury, harm to the surgical site, delayed discharge from the recovery room/ post anaesthetic care unit, an increased length of stay in hospital, the requirement of additional nursing staff to care for them and may display additional emotional and behavioural upsets in the weeks following surgery. Many factors have been postulated to be associated with the development of Emergence Delirium in children. However, to date the strength and nature of these associations has not been thoroughly investigated nor discussed considering the specific implications for contemporary nursing practice.

Aim

The aim of this scoping review is to provide an overview of Emergence Delirium in children, and a critical synthesis of evidence informing development of nursing interventions to prevent or minimise paediatric Emergence Delirium.

Methods

This scoping review was conducted guided by the PRISMA checklist. 14 peer-reviewed studies and guidelines published between 2000 and 2020 on Emergence Delirium in children and nursing practice were included in the deductive thematic analysis stage.

Results

The results found the anxiety of the child, the post-operative phase, continuity of care and medication administration were key themes in the nursing management of Emergence Delirium.

Conclusion

There is opportunity for further research to be conducted on child Emergence Delirium in different hospital systems with further exploration of nurse-led interventions.

Keywords:

• emergence delirium
• emergence agitation
• child
• nursing
• paediatric agitation
• paediatric anaesthesia

Impact statement

There is need and opportunity for nurse-led interventions to reduce post-anaesthetic anxiety and distress in children.

Plain language summary

When children wake up after surgery, they are sometimes very upset and confused. This puts the child at increased risk of harm and is distressing for nurses, health professionals and caregivers. We conducted a review of research published this century. We found the anxiety of the child, the medications they were given, continuity of care providers and the time immediately following surgery were key factors in the nursing management of upset and confusion in children.

Introduction

A child’s recovery from a general anaesthetic (GA) is influenced by a variety of factors. Whilst a vast array of research has been done to improve paediatric perioperative care, there is one complication that remains difficult to prevent, identify and manage: Emergence Delirium (ED). Emergence delirium (sometimes called ‘emergence agitation’) can also be observed in adults, but it is more commonly reported in children (Yu et al., 2010). It was first described as “post-anaesthetic excitement” by Eckenhoff et al. in 1961 and is currently defined as a distressed state post (GA) usually presenting within the first fifteen minutes of post-anaesthetic recovery, known as emergence (Hudek, 2009). Children, specifically those aged two to thirteen years may have an inability to open their eyes, speak coherently or follow simple instructions. They may be inconsolable, have trouble making eye contact and completing purposeful actions (such as taking a sip of water, or rolling over), and lack awareness of their surroundings. This can be accompanied by agitation, restlessness and confusion, crying, wild thrashing and screaming (Urits et al., 2020).

Background

Although assessment of Emergence Delirium is not always formally undertaken or documented, the Paediatric Anaesthesia Emergence Delirium Scale (PAED) scale is a widely accepted gold standard measuring tool for ED in children due to its high reliability and validity (Stamper et al., 2014). It measures five presenting factors: eye contact with caregivers, purposefulness of actions, awareness of surroundings, restlessness and if the child can be consoled. It can be applied in children aged zero to 13 years. Whilst ED events are usually short-lived, they can increase the risk of inadvertent injury, harm to the surgical site, delayed discharge from the recovery room/ post anaesthetic care unit (PACU), increased length of hospital stay and the requirement of additional nursing staff (Moore & Anghelescu, 2017). Kain et al. (2004) found that children with ED were 1.43 times more likely to show maladaptive behaviours for up to two weeks post-event than children who did not have ED. These behaviours include regression and aggression, enuresis, separation anxiety, eating and sleeping disturbances. Due to the varying use of diagnostic criteria, the reported incidence rates worldwide range up to 80% (Nair & Wolf, 2018), and despite much investigation by researchers specific underlying causes remain unclear.

Many factors have been associated with the development of ED in children. However, the strength and nature of these associations are not thoroughly investigated. Research by Vlajkovic and Sindjelic (2007) suggests the likelihood of children developing ED increases in conjunction with the use of inhaled or volatile anaesthetics such as Sevoflurane (Piramal Critical Care, 2021). These types of drugs gained popularity this century due to the rapid and smooth induction of a GA (Vlajkovic & Sindjelic, 2007).

The earliest researchers of ED in children, including Eckenhoff et al. (1961) believed the type of surgery to be a potential risk factor, noting child ED was often associated with tonsillectomies and circumcisions. A more investigated and explored risk factor for ED is the level of preoperative anxiety in the paediatric patient. Kain et al. (2006) revealed that children who were anxious pre-operative had a 9.7% incidence rate of ED, compared to those without (1.5%). Contrarily, Nair and Wolf (2018) confirmed that despite much speculation, the aetiology of ED remains unknown. Nonetheless, within the literature it is evident that strategies can be implemented to reduce its occurrence and improve outcomes for children undergoing a GA.

Aims/Objectives

There are many factors that may contribute to ED, this review focuses on nursing assessments, interventions and opportunities for intervention. It will provide a critical synthesis of existing evidence to inform the development of nursing interventions, form a basis of practice recommendations and identify further research avenues specific to paediatric nursing practice. The aim of this scoping review is to provide an overview of Emergence Delirium in children, and a critical synthesis of evidence informing the development of nursing interventions to prevent or minimise Emergence Delirium in children.

Methods

This scoping review search was conducted between March and April 2020, guided by the PRISMA checklist (Liberati et al., 2009).

Search strategy

A broad search of peer-reviewed, academic literature was carried out using the following keywords: emergence delirium (MeSH) or emergence agitation and child*, emergence delirium and prevent* or reduce, nurs* and paediatric agitation, paediatric and anaesthesia, pediatric and anesthesia, and nurs* care and paediatric anaesthesia. Scope limitations were added to restrict findings to peer-reviewed articles between 2000 and 2020. Searches were conducted using the following databases: ProQuest, CINAHL Plus, Cochrane Library, MEDLINE and Google Scholar.

Inclusion criteria

Inclusion criteria of articles at the title and abstract screening stage included the following:

• Search results were screened to find literature that applies to the prevention or management of ED and nurses/nursing

• These had to be written or translated into the English language

• Peer-reviewed empirical research studies, doctoral theses, and nursing-relevant guidelines

Exclusion criteria

Exclusion criteria of articles included the following:

• Existing literature reviews were excluded, but the reference lists were checked for possible study inclusion.

• Articles focused on the use of measuring scales or techniques in identifying ED

• Articles that investigated the different types of anaesthetic drugs used whose outcomes were ambiguous due to the difficulty in the application of outcomes on nursing practice.

A breakdown of this process according to the PRISMA checklist (Liberati et al., 2009) is shown in Figure 1.

Figure 1. Prisma flow chart.

Study selection

As shown in Figure 1, the initial search results produced 936 articles. The majority of full texts screened were excluded as they did not consider nursing care (usually focusing on the role of the anaesthetist and anaesthetic) and 12 were excluded as they were existing literature reviews. Title and abstract screening were undertaken by ME and VE . Full text screening was undertaken by ME and reviewed by VE and NA . Hand searches of the reference list of the existing literature reviews did not produce additional articles that met inclusion criteria.

Data extraction and synthesis

Details and findings relevant to the review aims were extracted from included studies [see Table 1]. Findings were coded manually on paper using colour codes (Young et al., 2020) and organised into phases of care: pre-operative, intra-operative and post-operative. A deductive approach was used to identify key areas specific to nursing practice (Young et al., 2020). This included: the anxiety of the child, the post-operative phase, continuity of care, and medication administration. All three authors contributed to data extraction and synthesis.

Table 1. Summary of included studies.

Author	Type	Pre-op	Intra-op	Post-op	Focus	Population	Outcome	Hospital Type	Location
Byun et al. (2018)	RCT			√	PACU	66 children aged 2–8, ASA 1&2	Lower ED occurrence	Tertiary Children’s Hospital	South Korea
Gonsalvez et al. (2018)	RCT	√	√		Medication given	80 children aged 2–8. ASA 1&2	No significant difference to ED occurrence	Unknown	Bengaluru, India
In et al. (2019)	Quasi-experimental			√	Parental visitation in PACU	93 children aged 3–6. ASA 1&2	No significant difference to ED	Tertiary Hospital	Seoul, South Korea
Kain et al. (2006)	Controlled Cohort Study	√		√	Anxiety of child	241 children aged 5–12. ASA 1&2	Anxiety correlates to behavioural difficulty post-op	Children’s Hospital	Connecticut, US
Manworren et al. (2004)	Audit of assessment tool			√	PACU nurse assessments	Ages 3–13	Treat ED as pain most effective	Children’s medical centre	Tennessee, US
Moore and Anghelescu (2017)	Guideline		√		Medication given in OT	Ages 2–11	Propofol or adjuvant is effective	Children’s Hospital	Tennessee, US
Mountain et al. (2011)	RCT	√			Use of pre-med	41 children aged 1–6. ASA 1&2	No significant difference	Unknown	US
Nolan (2019)	Guideline	√	√	√	Recommendations for anaesthetist	2–5 years old	Medications can reduce ED	Children’s Hospital	Bristol, UK
O’Sullivan and Wong (2013)	Guideline	√			More specific to anaesthetist. Includes behavioural interventions	Unstated	Support pre-op intervention required	Children’s Hospital	Toronto, Canada
Pan et al. (2019)	RCT	√			Pre-op prep	100 children aged 2–6	Lowered ED in blindfolded children	Large Hospital (6,000 beds)	Sichuan, China
Snell (2011)	Doctoral study, Iowa Quality Improvem-ent Project			√	Nurse education	<5 years old	Nurse education improved outcomes	General & Surgical Hospital	Colorado, US
Stewart et al. (2019).	RCT	√			Pre-op distraction i.e., use of tablets	102 children aged 4–12. ASA 1&2	Significantly lower ED	Paediatric Medical Centre	Texas, US
Voepel-Lewis et al. (2000).	Observational study	√			Nursing intervention	252 children aged Young group <6 years old Older group unstated	Screening for parents is beneficial in prediction of child’s behaviour	Mott’s Children’s Hospital	Michigan, US
Wennström et al. (2011).	RCT	√			Nursing intervention	93 children aged 5–11 ASA 1&2	Lowers post-op stress	Medium sized central hospital	Skövde, Sweden

Abbreviations: American Society of Anaesthesiologists’ (ASA), emergence delirium (ED), operating theatre (OT), Post Anaesthetic Care Unit (PACU), Randomised Controlled Trials (RCT).

Results

In total, 14 articles were included in this review, including six randomised controlled trials (RCTs), a doctoral study and three published clinical guidelines. The included studies were conducted in Canada, China, India, South Korea, Sweden, United Kingdom and the United States of America and were undertaken in a variety of clinical settings including Children’s Hospitals, Paediatric Medical Centres, and Medium – Large General Hospitals. Table 1 summarises the articles selected for this literature review.

The anxiety of the child

Managing the level of anxiety experienced by children was found to be important in preventing ED (Kain et al., 2006). Anxiety was thoroughly investigated by Kain et al. (2006) through their controlled cohort study of 241 children undergoing elective tonsillectomies and adenoidectomies. Each child and their parents were followed from five days pre-operative to two weeks post-operative and were assessed on their anxiety, temperament, and parental stress level. Findings showed a significantly higher proportion of children with pre-operative anxiety displayed agitated behaviour in the PACU, including crying and thrashing. The incidence rate was 9.7%, as opposed to 1.5% in children who were not anxious – a statistically significant difference between groups (p = 0.048). The implications of these findings for nursing practice are that those same children required an increased opiate intake, had higher levels of sleeping problems and difficulty eating for up to two weeks after discharge from hospital. These findings show a potential to inform and shape nursing practice in the care for children, particularly in the discharge information nurses provide to families of children who experienced ED.

Voepel-Lewis et al. (2000) also looked at anxiety but through a parental focus. Their observational study examined if parental insight of the child’s anxiety was a good predictor in their behaviour during their surgical experience. Evidence was gathered through a survey, which used scales to measure current anxiety, predicted separation anxiety, temperament, and activity levels. It collected data of 252 children aged one to ten over three months. The study determined that parents were better at predicting their child’s level of anxiety and behaviour throughout the perioperative journey, compared to nurses and anaesthetists. This finding shows the potential for nursing practice to incorporate parents and caregivers in the delivery of health care. This aligns well with the family-centred approach to child nursing, a practice that is advocated for by many studies, including the recent exploration by Boztepe and Kerimoğlu Yıldız (2017).

Stewart et al. (2019) trialled the use of an electronic tablet/device to distract children before undergoing a GA to test if this was an effective intervention to reduce pre-operative anxiety. In this RCT, 51 children were randomly assigned a tablet to play games and watch videos. A further 51 children were given usual care, with the administration of Midazolam as a means of sedation to ease induction and emergence. This study found that the use of a distraction tool reduced anxiety pre-operatively (P < .001) and lead to significantly fewer cases of irritability in the PACU (P = .001). Those same children were discharged home on average 25 min faster than those who received usual care and midazolam. This has a significant impact on patient flow in the PACU, financial cost on health systems and the nurse’s satisfaction in their job.

The results of this review highlight that the management of anxiety is important in the delivery of nursing care. There is no ‘gold standard’ intervention for this, however this review has shown that nursing care and interventions can make a significant impact on the occurrence of ED.

Post-operative phase

Three studies that were selected debated the best approach to the management of ED during the post-operative phase. An audit conducted by Manworren et al. (2004) used the Pain or Agitation Algorithm (Buss & Melderis, 2002) to differentiate pain from ED. The findings from this study were ambiguous. Whilst they found several effective strategies to measure pain, their recommendation for managing ED remained unchanged. This means that their audit did not change practice or policies. They found that it remains challenging to differentiate pain from ED and concluded that administering opiates was an effective intervention to manage both. This could, however, present a unique ethical challenge in the PACU. During the initial scoping stages, no articles were found that examined the ethical implications of administering analgesia to children who presented with ED but were without pain. This could be examined in future studies to reduce potential harm and effects from opiate administration.

A different focus on the post-operative phase comes from studies by Byun et al. (2018). Their prospective, single-centre, parallel-arm, double-blind RCT included 66 participants aged two to eight years. The intervention they were investigating was to play a recorded message to both groups. Half the group heard the child’s mothers voice, whilst the other half heard the voice of a stranger at the end of surgery. The message was: “(name of child), wake up, let’s go home with mommy, (name of child), wake up, open your eyes, take a deep breath”. This was repeated at ten-second intervals, accompanied by gentle stimulation from the PACU nurse. Participants were then assessed for ED. The result of the voice intervention showed ED was much lower in those who heard their mother’s voice, compared to those hearing a stranger’s voice [60.6% vs 24.2%, odds ratio, 95% CI: 4.88 (1.7-13.9); p = 0.006]. The findings of this study could have a significant impact on nursing practice and the involvement of family caregivers, aligning with the practice of family centred practice in the care for children (Hill et al., 2018).

Another study that focused on utilising a child’s parent was by In et al. (2019). This quasi-experimental study used 47 patients in the control group and 46 in the experimental group. The experimental group was taken through a parental visitation programme, which included a tour of the PACU, education on ED and use of infection prevention. This was done to familiarise the parent with the PACU and set expectations on what may happen during the post-operative phase to reduce any stress or initial shock at seeing their distressed child. ED was measured at ten-minute intervals on the patient’s arrival to the PACU. No statistically significant results were found between the two groups at the measured intervals (p = .558). However, In et al. (2019) did recognise that education and familiarising parents with the surgical environment did provide psychological support and reduction of anxiety for parents.

The results of this review found the post-operative phase of care important in managing ED once it had developed. The most effective intervention found was that by Byun et al. (2018) which depicted a practical nurse-led intervention with the potential to improve the child’s surgical journey and reduce rates of ED.

Continuity of care

The third theme found was continuity of care. Results from three studies demonstrated that input from the peri-operative team was best used when it occurred both before and after surgery. An RCT conducted by Pan et al. (2019) set out to find if blindfold training before surgery was helpful in the prevention of ED. The trial used 100 children aged two to six years, 46 of which were blindfolded before surgery to simulate what they could expect after receiving ophthalmic surgery. Findings showed that 7% of children who did not receive blindfolding developed post-operative ED, as opposed to only 3% in blindfolded children (p = >.05). This study could be used to develop new methods to prepare and reduce stress for children by simulating realistic scenarios. It is a practical method that could be an effective nurse-led intervention.

Snell (2011) investigated the education given to the child’s parents by nurses. Snell (2011) found that thorough education and dialogue with parents by nurses were effective in the management of ED in 43% of cases (compared to those without intervention), as measured by staff and parental surveys. It found that staff also felt more comfortable implementing non-pharmaceutical interventions after education to the parents was given. This study highlighted the benefit of continuing dialogue with parents but also upskilling nurses around the topic of ED and how to undertake appropriate nursing interventions effectively.

With awareness of stress experienced by both the child and their parent being a risk factor for ED, an RCT by Wennström et al. (2011) used perioperative dialogue in 93 children aged five to 11. Perioperative dialogue is a model of care where the patient meets the same nurse at every stage of care. Their method, like Snell (2011) and Pan et al. (2019), found that input at every stage of surgery, thereby also every level of nursing care, was beneficial in reducing stress levels (p = 0.003). The results showed significant reduction of stress in children who received Perioperative Dialogue, shown through cortisol measurement and analysis. Continuity of care is a theme efficiently explored by Pan et al. (2019), Snell (2011) and Wennström et al. (2011). Their studies highlight the benefit of managing ED at all stages of care and could prove beneficial in adapting nursing practice.

Medication administration

Having explored the non-medical intervention styles, the final theme drawn from this literature is that ED is most commonly managed with anaesthesia or medication. Management guidelines by Moore and Anghelescu (2017), Nolan (2019), and O’Sullivan and Wong (2013) all support the use of Midazolam as a paediatric anaesthetic premedication to ease the child in the wake-up phase. This is further supported in RCTs conducted by Gonsalvez et al. (2018) and Mountain et al. (2011) who all recorded benefits of using premedication (the former using Dexmedetomidine, and the latter Midazolam) in reducing the rate of ED in the PACU. However, two core limitations exist within these studies. The first in the study by Mountain et al. (2011) was the oversight of the bioavailability of their chosen medication. Due to a 66% greater uptake of Dexmedetomidine in buccal administration compared to oral, it was less effective as a premedication than initially hypothesised. The second is that Dexmedetomidine was not an approved drug for use in children in the United States during their study. The results might have been more impacting on nursing practice if that had been considered before commencing the study. An incidental finding by Gonsalvez et al. (2018) was the timing of the administration of midazolam. Whilst no impact on ED was found, they noticed that it did increase the length of stay in recovery due to a longer period of drowsiness. This made no impact on ED incidence but does infer that it could be beneficial to the patient to be administered toward the beginning of surgery, as opposed to the end.

Whilst these interventions are not nurse led, they are still effective methods to manage ED and nurses often play a key role in their administration.

Discussion

Overall, our analysis of 14 studies identified and synthesised current evidence for nursing interventions to prevent or minimise ED in children. Our findings showed that important considerations for nurses centre on the anxiety of the child, the post-operative care phase, continuity of care, and medication administration.

Gaps in existing literature

There are several gaps in existing literature relating to the management of ED in children. There is a lack of research evaluating nursing interventions which may prevent or minimise ED. Most studies found were those pertaining to anaesthetic agents and intraoperative medication, often administered by specialist nurses. Two guidelines by Nolan (2019) and O’Sullivan and Wong (2013) include this in their considerations of the use of propofol and ketamine to help reduce ED. Whilst nurses can update peers on these new findings and guidelines, it is typically the anaesthetist’s decision which medication will be prescribed. This leaves a large gap in exigent research specific to the field of paediatric ED and nursing practice. Of the studies found that addressed this gap, the most recent and successful were those by Byun et al. (2018), Pan et al. (2019) and Stewart et al. (2019). Their practical solutions could be led and implemented by nurses. So far, research is primarily single intervention focused, meaning that it is difficult to find evidence that these methods combined have value to the outcome of a child’s GA. Opportunities exist for future research to combine medication and non-medication approaches to managing ED in children.

Most of the successful intervention studies included in this review were carried out at paediatric specialist facilities (n = 8). Where children undergo surgery in mixed adult–child surgical facilities, this may have an impact on their care and experience. None of the studies included in this review investigated the effect of children sharing the pre-operative waiting room with adults. It is unclear if the outcome of the successful studies was impacted by the paediatric specialty setting.

Further gaps in research pertain to cultural differences. Four studies that were discussed in this review were undertaken in Asia (South Korea, China, and India), nine in the United States or Canada, one in England, and one in Sweden. Wennström et al. (2011) alluded that in Swedish culture, hospital staff are seen as trustworthy. Cultural attitudes towards hospitals and health professionals are likely to have an impact on perioperative anxiety and experience for children and families, but little is known about how these impacts on ED, specifically.

When measuring the outcome of trials, the most common method adopted was the use of the Paediatric Anaesthesia Emergence Delirium Scale (PAED) scale (Sikich & Lerman, 2004). The PAED scale is a widely accepted gold standard measuring tool for ED in children due to its high reliability and validity (Stamper et al., 2014). The PAED scale was utilised by eight articles selected, five of which were RCTs (Byun et al., 2018; Gonsalvez et al., 2018; In et al., 2019; Moore & Anghelescu, 2017; Mountain et al., 2011; Pan et al., 2019; Stewart et al., 2019; Wennström et al., 2011). There were other measuring tools used in combination with the PAED score. The FLACC pain score was used in three studies (Merkel et al., 1997) and the Wong-Baker pain scale in three others (Wong & Baker, 1988). There was little criticism found in the literature for its use, other than by Nolan (2019), who argued that a Watcha score is simpler to administer compared to the PAED Scale. The Watcha score is simpler because it is based on sedation and agitation levels and does not account for other behavioural traits. Nolan (2019) further argues that not all children behave the same before a GA. Many infants and children, especially those with behavioural or developmental challenges, have difficulty maintaining eye contact, exerting purposeful actions and lack awareness of surroundings at baseline.

In this review, 80% of trials only conducted their research on children with an American Society of Anaesthesiologists (ASA) of one or two. The ASA physical status classification is a system used to assess a patient’s pre-anaesthetic medical wellbeing to predict their operative risk (American Society of Anaesthesiologists, 2020). A patient’s wellbeing is scored from ASA status one to six, with one being a healthy patient, and six being a brain-dead patient undergoing surgery for organ donation purposes. The trials in this review that mentioned this system only included children in ASA one or two, meaning the children would have normal health or mild systemic disease (Byun et al., 2018; Gonsalvez et al., 2018; In et al., 2019; Kain et al., 2000; Kain et al., 2006; Mountain et al., 2011; Stewart et al., 2019; Wennström et al., 2011). Each of these studies, plus those done by Voepel-Lewis et al. (2000), also excluded children with developmental delay or cognitive impairment. It could be argued that this is of benefit to the study as it is easier to rule out a pre-existing or underlying condition as being the causative factor in developing ED. However, children with pre-existing cognitive, mental and/or emotional conditions, such as autism or a developmental delay, may have higher rates of behavioural problems in the PACU and therefore could have been considered in these studies or have been discussed in the limitations of their studies (Weldon, 2007).

Strengths and limitations

This integrative scoping review investigated nursing interventions associated with preventing or managing paediatric ED. Strengths of this review include a systematic search for all studies published this century. The in-depth analysis of each article was beneficial in the generation of themes and key findings that apply to nursing practice. Limitations of the review pertained to the lack of research articles relevant to nursing practice, the small number of articles that provided interventions without the use of medication, and the relatively small amount of available literature, considering that 8 out of the 14 studies were published within the past ten years. The use of keywords could have been broader to scope articles relating to anxiolysis. Another limitation was the distinct lack of qualitative research, as most studies were RCTs or other clinical trials. Most of the studies relied on pre-existing statistics describing the incidence and severity of ED.

Implications for future research

This review has found that reduction of pre-operative anxiety is a major factor in preventing the occurrence of ED in children. This finding raises the question: as nurses how do we minimise pre-operative anxiety in children effectively and with limited time and resource constraints, while operating within the confines of our hospital systems? And, how to do so in different cultural, social, and economic circumstances? The trial by Pan et al. (2019) who simulated post-operative experiences by blindfolding children before ophthalmic surgery, could be expanded into other operations to set realistic expectations. Furthermore, the findings from Stewart et al. (2019) to distract children with the use of an electronic tablet and the study Byun et al. (2018) to play a mothers voice on waking could be implemented together and incorporated into policies and practices to improve short and long term outcomes for children. Greater research is needed to determine the utility, suitability, and potential benefit of these nursing interventions within the diverse hospital systems that we care for paediatric patients undergoing and recovering from GA.

Conclusion

This scoping review included 14 empirical studies and nursing management-focused guidelines, published between 2000 and 2019 on ED in children and nursing practice. Detailed analysis of the articles found the anxiety of the child, the post-operative phase, continuity of care and medication administration were key themes in the nursing management of ED. There is opportunity for further research to focus on quantifying the issue of ED in different hospital systems and further exploring the potential nursing interventions that could make a difference on the outcome of ED in children.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Conflict of interest statement

The authors report no actual or potential conflicts of interests.

Additional information

Funding

This research was funded in part by a Bachelor of Nursing Honours Scholarship for ME by Tauranga Hospital, Bay of Plenty District Health Board. VE was funded by a Lotteries Health Research Fellowship #128096.