Faster Pain Relief for Children With Fractures

When a child arrives in the Emergency Department (ED) with a broken bone, getting her pain relief as quickly as possible is a top priority. That’s why when clinicians in CHOP’s ED found that patients were sometimes waiting more than an hour for pain relief — too long by CHOP’s standards — they addressed the issue by implementing a quality improvement project.

The first step was to use data to identify why patients weren’t getting faster pain relief in the ED. Then, changes were made in the care process to address these problems.

Since the project launched in May 2014, new data shows that the number of patients getting faster-acting medication has nearly tripled. And when opioids are required, the time it takes for orders to be placed has been cut in half.

Developing an approach to improve care

This quality improvement initiative was taken on by a team of practitioners and family partners led by James Callahan, MD; Keith Baldwin, MD, MPH, MSPT; Mary Wood, RN; Christopher Valente, MD; Aileen Schast, PhD; Mary Kate Funari, RN, BSN; Tiffani Johnson, MD, MSc; and Rachel Freedman.

The team also included other physicians, nurse practitioners and nurses from the ED and orthopedics, radiology technologists and members of CHOP’s family faculty, who provided input on the ED experience from the family perspective.

The group found three main issues that were leading to longer wait times for pain relief:

• Acetaminophen was sometimes used instead of ibuprofen. For children with fractures, ibuprofen works better than acetaminophen and is typically the more appropriate choice.
• Intravenous (IV) fentanyl was used instead of intranasal (IN) fentanyl. Fentanyl, a fast-acting opioid (narcotic) pain reliever, can be given much more quickly through the nose (intranasally).
• Too much time between patient evaluation and orders for opioids. For children in severe pain who required opioids, there was too much time between a practitioner first evaluating a patient and the order being placed for the medication they needed.

Addressing these would improve the quality of care for children in the ED with fractures.

Educational and practice support measures

The first step in addressing these problems was to create educational and practice support methods for every clinician in the ED.

Education about the larger issue. The quality improvement team started by presenting baseline data about the use of acetaminophen, ibuprofen, and IV and IN fentanyl to all clinicians. They also told them about the order times for opioids, and how they hoped to change prescribing behavior to improve care.

Regular reminders. Staff are reminded about the importance of this quality improvement project with Safety Tips of the Day during shift changes, during divisional and nursing meetings, in weekly educational announcements, within the Fractures Order Set used by practitioners, and on-screen savers in clinician work areas, and screen savers in patient rooms to encourage families to speak to providers if their child was in pain.

Progress reports. Practitioners frequently review data about their own prescribing behaviors, so they can see how they compare to their peers, and how often they follow recommended guidelines.

Review of delayed orders. When there is a delay in an opioid order, it’s reviewed, and feedback is provided to the practitioner.

Measurable change

The first eight months of data collected, between August 2014 and March 2015, showed significant improvements in fracture care in the ED.

For patients not receiving opioids:

• Ibuprofen administration increased, from 59 percent to 79 percent  of patients

For patients receiving opioids:

• IN fentanyl use increased from 23 percent to 60 percent
• Median time from evaluation to opioid order decreased from 41 to 23 minutes
• Median arrival to administration decreased from 103 to 95 minutes

"We’ve made good strides,” says Callahan. “It’s great to see our practitioners embracing these simple changes that make such a huge difference in the patient and family experience.”