Improving Pain Management for long bone fractures in ED through Peer Review and
Feedback: a Children’s Hospital Emergency Department QI initiative
Manu Madhok, MD, MPH, Meixia Liu, MS
Introduction:
Pain is the most common cause for seeking care in Emergency Departments (EDs) [1, 2, 3]. As many as
three-quarters of ED patients list pain as part of the reason for their presentation. Despite this high
prevalence, pain is often poorly treated in ED settings [4, 5, 6, 7] .This finding has been especially
pronounced in the subgroup of pediatric patients.
Acute long bone fracture is the most common presenting complaint for pediatric ED patients in
moderate to severe pain. A clinical report published in Pediatrics in 2004 stated that “optimal pain
management requires expeditious pain assessment and the rapid administration of systemic opioid
medication to patients in severe pain.” [9]. This report also provided guidance for appropriate goals
related to acute pain management. Even with this guidance, the timely and effective elimination of
fracture pain in children is often not achieved [10-14]. "Defining Quality Performance Measures for
Pediatric Emergency Care” [10,11] is published by Emergency Medical Services for Children (EMSC)
program and is in response to “Emergency Care for Children: Growing Pains,” the 2006 Institute of
Medicine (IOM) report that recommends the development of national standards for emergency care
performance measurement. They recommend utilizing age-appropriate pain scale and show
documented improvement in pain score within 90 minutes of arrival. This quality assurance and
improvement project seeks to improve the health care of children by optimizing the treatment of pain
associated with long bone fractures.
Objectives
Baseline Data phase
1. To calculate the baseline data for time to pain medication for long bone fractures in children
presenting to ED.
2. To improve the time to pain medication for long bone fractures in children presenting to ED by 20% in
12 months with a goal to exceed national benchmark of 60 minutes.
Quality Improvement Phase
To improve pain management processes by adopting ‘Long Bone Fracture Bundle’.
Evaluate if peer pressure affects performance at provider level.
Evaluate if the change in pain assessment at triage translates to minimizing the disparity in time to pain
medication for minorities.
Methods
A retrospective chart review of patients with diagnosis of long bone fractures seen in the Children’s
Hospitals and Clinics of Minnesota Emergency Department from 1/1/08 to 12/31/10 was accomplished
using computerized database. Minneapolis and St. Paul are the Twin Cities of Minnesota and have their
own Children’s Hospital campus and see about 45,000 patients per year at each site. The long bone
fractures included fractures of humerus, radius-ulna, femur, ankle and tibia-fibula. Time to pain
medication was calculated as the time between arrival to ED and medication administration. For each
patient encounter multiple data fields were collected including demographic, social and economic
indicators along with clinical variables of pain score, type of fracture, type of pain medication, time of
day etc.
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Quality Improvement Initiatives:
Based on the results of baseline study, QI measures were initiated to address following issues.
The median time to pain medication exceeded national benchmark when data for all patients was
analyzed. However, it varied significantly when different variables were analyzed. The study identified
three primary opportunities for intervention and improvement:
1.) Whites received medication faster and by IV route when compared to non-whites
2.) Pain medication by IV treatment was fastest but utilized in 54% patients
3.) Certain physicians were faster at administering medication
Emergency Department designed ‘Long Bone Fracture Bundle’ to address these discrepancies via an
innovative program. It included education at nursing level where assessment and timely treatment of
pain was discussed at monthly meetings and daily huddles. The variation in time to pain medication
amongst patients was presented and possible explanations were explored. The racial difference for pain
tolerance was explored in detail. We attempted to compensate for this difference by considering an
additional point on pain score when assessing in triage. This was felt to be not appropriate as pain score
recorded is patients’ self reporting of pain on FACES scale. A change in hospital sedation policy was
instituted where Intranasal Fentanyl administration was established as analgesia and not sedation.
Nurses were educated regarding appropriate monitoring when administering Intranasal Fentanyl and
did not need to fill sedation paperwork. This removes hesitancy on using Fentanyl in a new route.
Pharmacist provided teaching on new atomizers that need to be connected to syringe when
administering intranasal Fentanyl. Physicians were provided their individual data on median time to
pain medication and the data of their peers in a blinded fashion. The idea of un-blinding top performers
was discussed amongst all providers but not instituted as many factors influence this time which may
not be under direct control of treating physician. The data from first quarter was compared to third
quarter as all education and interventions were instituted in the second quarter.
Statistics
Frequency distributions for dichotomous variables such as gender and race, and median (range) for
continuous variables such as age were used to describe the data. Non-parametric Mann-Whitney test or
Kruskal-Wallis H test were used to compare the time to pain medication administration between
different variables as appropriate. Chi-square test was used to compare the dichotomous variables
between different groups. All statistical analyses were done using SPSS 15.0.
Results of baseline data
2206 patients (Male 1386, Female 820) meeting ICD9 codes and valid data fields were included in data
analysis. There was no significant difference in the three years (2008 with756 patients, 2009 with 708
patients and 2010 with 841 patients). The distribution of type of fractures is described below.
Humerus
Radius/Ulna
Femur
Tibia/Fibula
Ankle
566
1116
162
173
189
2
Median time to Pain medication administration was 50.35 minutes in baseline data.
It did not vary significantly over 3 years.
2008: 49.20 min
2009: 51.75 min
2010: 49.20 min
Amongst various parameters, It varied significantly with regards to Gender, Race, Language spoken,
Insurance status, Triage acuity level, Pain score and Type of Pain medication. (Table 1). The median time
to pain medication varied amongst Providers from 35 minutes to 90 minutes.
There was no significant difference when interpreter services were used.
When Race and Route were studied, non-white patients were less likely to receive IV pain medication
when compared to white patients (48.4% vs. 57.8%, p<0.001).
Table 1 Clinical Parameters and variability in time to pain medication
Clinical parameter
Gender
Female (n=820)
Male (n=1386)
Race, White
No (n=768)
Yes (n=1278)
Language, English
No (n=300)
Yes (n=1906)
Arrival Hour
7Am-3PM (n=571)
3PM-11PM (n=1508)
11PM-7AM (n=127)
Medicaid
No (n=1520)
Yes (n=686)
Acuity Level
Emergent (n=10)
Critical (n=1119)
Acute (n=324)
Urgent (n=737)
Non-urgent (n=16)
Pain score
<=4 (n=684)
>4 (n=1374)
Route
Oral (n=1014)
IV/IM (n=1147)
Nasal (n=45)
Narcotics
No (n=987)
Yes (n=1211)
Minute to pain medication
administration
P-value
0.003
53.2 (1, 335)
48.4 (0, 460)
0.007
53.4 (1, 460)
48.4 (0, 350)
0.023
53.4 (1, 312)
49.9 (0, 460)
0.004
45.8 (2, 460)
50.6 (0, 452)
56.6 (1, 205)
0.006
48.6 (0, 350)
53.8 (1, 460)
<0.001
38.2 (4, 156)
39.2 (0, 460)
62.9 (2, 452)
67.6 (2, 336)
53.6 (34, 210)
<0.001
61.3 (1, 452)
45.0 (0, 460)
<0.001
62.2 (0, 350)
43.3 (1, 460)
35.1 (4, 220)
<0.001
62.5 (0, 318)
43.3 (1, 460)
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Results of Quality Improvement Phase
This hospital’s quality improvement project to improve the time-to-pain medication associated with long
bone fractures, racial differences and provider variability took place in second quarter of 2011. A chart
review using institutional computerized database was performed for first (Jan-March) quarter and third
(June-August) quarter of 2011. It identified 387 pediatric patients with acute long bone fractures.
Table 2 lists patient characteristics and other comparisons between Pre and Post groups which showed
no difference amongst the two groups. Table 3 shows improvement in median time in minutes to pain
medication for various groups by race. Table 4 illustrates change in median time in minutes to pain
medication over the course of study time. There was increase in utilization of intranasal Fentanyl from
3.4% in baseline data to 16.2% in pre-intervention and 25.9% in post-intervention periods. There was
not enough data to compare change in provider variability because of smaller sample size. However, a
new standing order protocol for pain medication is being instituted where a practitioner can activate the
treatment in triage and nurse can initiate the pain control in an expedited manner.
Table 2 Patient Characteristics and other Comparisons between Pre and Post groups
Pre-group (n=132)
Post-group (n=255)
(Jan-Mar 2011)
(Jun-Aug 2011)
Gender, male
84 (63.6%)
153 (60.0%)
Language, English
115 (87.1%)
215 (84.3%)
Race
Asian
4 (3.2%)
20 (8.3%)
Black/African American
23 (18.5%)
47 (19.5%)
Hispanic/Latino
14 (11.3%)
16 (6.6%)
White/Caucasian
74 (59.7%)
136 (56.4%)
Other
9 (7.3%)
22 (9.1%)
Arrival Hour
7AM-3PM
41 (31.1%)
82 (32.2%)
3PM-11PM
87 (65.9%)
148 (58.0%)
11PM-7AM
4 (3.0%)
25 (9.8%)
Campus
MPLS
70 (53.0%)
126 (49.4%)
STP
62 (47.0%)
129 (50.6%)
Acuity level
Emergent
0
5 (2.0%)
Critical
58 (43.9%)
128 (50.2%)
Acute
42 (31.8%)
75 (29.4%)
Urgent
31 (23.5%)
47 (18.4%)
Non-urgent
1 (0.8%)
0
Medicaid
49 (37.1%)
91 (35.7%)
Interpreter used
8 (6.1%)
22 (8.6%)
Route
IV
58 (43.9%)
103 (40.4%)
Nasal
20 (15.2%)
61 (23.9%)
PO
54 (40.9%)
91 (35.7%)
Narcotics
78 (59.5%)
164 (64.3%)
White
74 (59.7%)
136 (56.4%)
Pain score*
6.0 (1, 10)
7.0 (1, 10)
p-value
0.486
0.460
0.208
0.035
0.5
0.082
0.078
0.371
0.129
0.359
0.552
0.325
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Table 3 Median minutes to pain medication
Pre
Median time to pain
medication
n
Post
p-value
Median (range)
n
Median (range)
57.5 (3, 335)
255
46 (1, 237)
0.008
Other
23
14
74
9
60 (16, 88)
64 (12, 232)
79 (25, 180)
45 (6, 335)
71 (18, 181)
20
47
16
136
22
50.5 (19, 129)
56 (11, 232)
40.5 (1, 141)
45 (4, 237)
42 (14, 190)
0.970
0.059
0.064
0.528
0.174
White
Non-white
74
50
45 (6, 335)
67.5 (12, 232)
136
105
45 (4, 237)
49 (1, 232)
0.528
0.004
English
Non-English
115
17
55 (6, 335)
64 (31, 232)
215
40
46 (1, 127)
50.5 (11, 141)
0.035
0.06
Asian
3
15
12
56
8
6 (4, 10)
8 (1, 10)
5.5 (2, 10)
6.5 (1, 10)
8 (2, 10)
13
38
14
105
18
4 (1, 10)
8 (1, 10)
6.5 (2, 10)
7 (1, 10)
8.5 (1, 10)
0.364
0.686
0.252
0.440
0.724
Median time to pain
132
medication (min)-overall
Race
Asian 4
Black/African American
Hispanic/Latino
White/Caucasian
Race
Language
Pain Score
Race
Black/African American
Hispanic/Latino
White/Caucasian
Other
Table 4 Median minutes to pain medication by admission Month
Month
Jan
Feb
Mar
Jun
Jul
Aug
n
38
48
46
111
75
69
Median (range)
61 (11, 185)
58.5 (9, 335)
47.5 (6, 214)
49 (5, 232)
48 (1, 237)
39 (4, 204)
Conclusion
The time to pain medication at Children's Hospital exceeds national benchmark and quality
improvement interventions improved time to pain medication for all races. There was an increase in
utilization of intranasal Fentanyl after the change in hospital sedation policy. A standing order protocol
for pain medication may help expedite the pain medication. The disparity in care based on language,
race and insurance status supports need for improvement in these spheres. This difference has also
been reported in previous studies. Racial and cultural differences need to be studied further to identify
if there is truly a variable tolerance to pain or hesitation to reporting based on socio-cultural factors or
health literacy.
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