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LO35: A province-wide quality improvement collaborative for treatment of children's pain in Alberta's emergency departments
- J. Thull-Freedman, E. Pols, A. McFetridge, S. Libbey, K. Lonergan, B. Lethebe, S. Ali, A. Stang
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S19
- Print publication:
- May 2020
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Background: Pediatric pain is often under-treated in emergency departments (EDs), causing short and long-term harm. In Alberta EDs, children's pain outcomes were unknown. A recent quality improvement collaborative (QIC) led by our team improved children's pain care in 4 urban EDs. We then spread to all EDs in Alberta using the Institute for Healthcare Improvement Framework for Going to Full Scale. Aim Statement: To increase the proportion of children <12 years who receive topical anesthetic before needle procedures from 11% to 50%; and for children <17 years with fractures: to 1) increase the proportion receiving analgesia from 31% to 50%; 2) increase the proportion with pain score documentation from 24% to 50%, and 3) reduce time to analgesia from 60 to 30 minutes, within 1 year. Measures & Design: All 97 EDs in Alberta that treat children were invited. Each was asked to form a project team, attend webinars, develop key driver diagrams and perform PDSA tests of change. Sites were given a monthly list of randomly selected charts for audit and entered data in REDCap for upload to a provincial run chart dashboard. Baseline performance measurement informed aims. Measures included proportion of children <12 years undergoing a lab test who received topical anesthetic, and for children <17 years with fracture, the proportion with a pain score, proportion receiving analgesia and median minutes to analgesia. Length of stay and use of opioids were balancing measures. Control charts were used to detect special cause. Interrupted time series (ITS) was performed to assess significance and trends. Evaluation/Results: 36 sites (37%) participated, including rural and urban sites from all regions. 8417 visits were audited. 23/36 sites completed audits before and after tests of change and were analyzed. Special cause occurred for all aims. The proportion receiving topical anesthetic increased from 11% to 30% (ITS p < 0. 001). For children with fractures, the proportion with pain scores increased from 24% to 34% (ITS p = 0.21, underlying trend present), proportion receiving analgesic medication increased from 31% to 39% (ITS p = 0.41, underlying trend present) and minutes to analgesia decreased from 60 to 28 (ITS p < 0. 01). There was no increase in length of stay or use of opioid medications. Discussion/Impact: A pragmatic approach encouraging locally led change was well-received and key to success. The QIC method shows promise for improving outcomes in diverse EDs across large geographic areas. Next steps include further spread and sustainability measurement.
LO35: Characterizing pain in children with acute gastroenteritis presenting to the emergency department
- S. Ali, C. Maki, J. Xie, B. Lee, T. Graham, O. Vanderkooi, S. MacDonald, N. Poonai, J. Thull-Freedman, M. Rajagopal, N. Dow, M. Sivakumar, S. Freedman, Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE), Pediatric Emergency Research Canada (PERC)
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, pp. S19-S20
- Print publication:
- May 2019
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Introduction: Although acute gastroenteritis is an extremely common childhood illness, there is a paucity of literature characterizing the associated pain and its management. Our primary objective was to quantify the pain experienced by children with acute gastroenteritis in the 24-hours prior to emergency department (ED) presentation. Secondary objectives included describing maximum pain, analgesic use, discharge recommendations, and factors that influenced analgesic use in the ED. Methods: Study participants were recruited into this prospective cohort study by the Alberta Provincial Pediatric EnTeric Infection TEam between January 2014 and September 2017. This study was conducted at two Canadian pediatric EDs; the Alberta Children's Hospital (Calgary) and the Stollery Children's Hospital (Edmonton). Eligibility criteria included < 18 years of age, acute gastroenteritis (□ 3 episodes of diarrhea or vomiting in the previous 24 hours), and symptom duration □ 7 days. The primary study outcome, caregiver-reported maximum pain in the 24-hours prior to presentation, was assessed using the 11-point Verbal Numerical Rating Scale. Results: We recruited 2136 patients, median age 20.8 months (IQR 10.4, 47.4); 45.8% (979/2136) female. In the 24-hours prior to enrolment, 28.6% (610/2136) of caregivers reported that their child experienced moderate (4-6) and 46.2% (986/2136) severe (7-10) pain in the preceding 24-hours. During the emergency visit, 31.1% (664/2136) described pain as moderate and 26.7% (571/2136) as severe. In the ED, analgesia was provided to 21.2% (452/2131) of children. The most commonly administered analgesics in the ED were ibuprofen (68.1%, 308/452) and acetaminophen (43.4%, 196/452); at home, acetaminophen was most commonly administered (77.7%, 700/901), followed by ibuprofen (37.5%, 338/901). Factors associated with analgesia use in the ED were greater pain scores during the visit, having a primary-care physician, shorter illness duration, fewer diarrheal episodes, presence of fever and hospitalization. Conclusion: Although children presenting to the ED with acute gastroenteritis experience moderate to severe pain, both prior to and during their emergency visit, analgesic use is limited. Future research should focus on appropriate pain management through the development of effective and safe pain treatment plans.
LO22: Improving the pain experience for children with limb injury: a city-wide quality improvement collaborative
- J. Thull-Freedman, T. Williamson, E. Pols, A. McFetridge, S. Libbey, K. Lonergan, E. Lang, A. Stang
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, p. S14
- Print publication:
- May 2018
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Introduction: Undertreated pain is known to cause short and long-term harm in children. Limb injuries are a common painful condition in emergency department (ED) patients, accounting for 12% of ED visits by children. Our city has one pediatric ED in a freestanding children’s hospital and 3 general ED’s that treat both adults and children. 68% of pediatric limb injuries in our city are treated in the pediatric ED and 32% are treated in a general ED. A quality improvement (QI) initiative was developed at the children’s hospital ED in April 2015 focusing on “Commitment to Comfort.” After achieving aims at the childrens hospital, a QI collaborative was formed among the pediatric ED and the 3 general ED’s to 1) improve the proportion of children citywide receiving analgesia for limb injuries from 27% to 40% and 2) reduce the median time to analgesia from 37 minutes to 15 minutes, during the time period of April-September, 2016. Methods: Data were obtained from computerized order entry records for children 0-17.99 years visiting any participating ED with a chief complaint of limb injury. Project teams from each site met monthly to discuss aims, develop key driver diagrams, plan tests of change, and share learnings. Implementation strategies were based on the Model for Improvement with PDSA cycles. Patient and family consultation was obtained. Process measures included the proportion of children treated with analgesic medication and time to analgesia; balancing measures were duration of triage and length of stay for limb injury and all patients. Site-specific run charts were used to detect special cause variation. Data from all sites were combined at study end to measure city-wide impact using 2 and interrupted time series analysis. Results: During the 3.5-year time period studied (April 1, 2014-September 30, 2017), there were 45,567 visits to the participating ED’s by children 0-17.99 years with limb injury. All visits were included in analysis. Special cause was detected in run charts of all process measures. Interrupted time series analysis comparing the year prior to implementation at the childrens hospital in April 2015 to the year following completion of implementation at the 3 general hospitals in October 2016 demonstrated that the proportion of patients with limb injury receiving analgesia increased from 27% to 40% (p<0.01), and the median time from arrival to analgesia decreased from 37 to 11 minutes (p<0.01). Balancing measure analysis is in progress. Conclusion: This multisite initiative emphasizing “Commitment to Comfort” was successful in improving pain outcomes for all children with limb injuries seen in city-wide ED’s, and was sustained for one year following implementation. A QI collaborative can be an effective method for spreading improvement. The project team is now spreading the Commitment to Comfort initiative to over 30 rural and regional EDs throughout the province through establishment of a provincial QI collaborative.
MP22: Improving treatment of children’s presenting and procedural pain for emergency department visits: a province-wide quality improvement collaborative
- J. Thull-Freedman, E. Pols, A. McFetridge, T. Williamson, S. Libbey, S. Ali, K. Lonergan, A. Stang
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, p. S48
- Print publication:
- May 2018
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Introduction: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) was successful in improving treatment of children’s pain across 4 EDs in our city. A new QIC was then formed among EDs across our province to improve treatment of presenting and procedural pain. Aims were to improve the proportion of children <12 years of age who receive topical anesthetic before needle procedures from 13% to 50%; and for children <17 years of age with fractures: to 1) improve the proportion who receive analgesic medication from 35% to 50%; 2) improve the proportion who have a documented pain score from 23% to 50%, and 3) reduce median time to analgesia from 59 minutes to 30 minutes, within 1 year. Methods: Invitations to participate in the QIC were sent to all 113 EDs in the province that treat children and had not participated in the previous QIC. Each site was asked to form a project team, participate in monthly webinars, develop key driver diagrams and project aims, undertake PDSA tests of change, and audit charts to assess performance. Sites are given a list of 20 randomly selected charts per month for audit. Audit data was entered into REDCap and uploaded to a provincial run chart dashboard. All participating sites received a “comfort kit” consisting of distraction items for children as well as educational materials. Measures of presenting pain included proportion of children <17 years with a diagnosis of fracture who have a documented pain score, proportion who receive an analgesic medication, and minutes to analgesia. The measure for procedural pain was the proportion of children <12 years who receive topical anesthetic prior to a needle procedure for a laboratory test. Length of stay for pediatric patients and all patients were balancing measures. Run charts were used to detect special cause. Difference in proportions were compared using 2. Final analysis will include interrupted time series. Results: 34 of 113 invited sites (30%) agreed to participate, including rural and regional representation from all geographic zones; 4222 visits since June 2016 were analyzed. Implementation began June 2017. Comparing the first 4 months following implementation to the preceding year, the proportion of children receiving topical anesthetic prior to needles increased from 13% to 25% (p<0.001). For children with fractures, the proportion with pain scores increased from 23% to 35% (p<0.001), proportion receiving analgesic medication increased from 35% to 42% (p<0.001), and median minutes to analgesia decreased from 59 to 43. Insufficient time points at this stage preclude identification of special cause. Conclusion: This province-wide QIC has already resulted in significant progress toward aims during the first 4 months of implementation. The QIC approach shows promise for improving pain outcomes in children visiting diverse EDs across a province.
MP005: Treating and Reducing Anxiety and Pain PEDs (TRAPPED 2): time for action - a PERC project
- E. D. Trottier, S. Ali, G. Meckler, M. Blachet, A.S. Stang, R. Porter, S. Le May, A. Dubrovsky, M. Chan, R. Jain, T. Principi, G. Joubert, A.J. Kam, J. Thull-Freedman, G. Neto, M. Lagacé, J. Gravel
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, pp. S67-S68
- Print publication:
- May 2016
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Introduction: Multiples barriers to appropriate analgesia are reported in the paediatric emergency department (PED), including limited accessibility to effective strategies. Our objective: was to evaluate the improvement in the accessibility of pain and anxiety management strategies in Canadian PEDs, after the creation of a national pediatric pain Quality Improvement Collaborative (QIC), through Pediatric Emergency Research Canada (PERC). Methods: In 2013, the TRAPPED 1 survey was administered to Canadian PEDs, in order to evaluate what resources were in place for pain and anxiety management. A pain QIC was then created to stimulate the implementation of new strategies, through information sharing between PEDs. In 2015, the TRAPPED 2 cross sectional survey was administered. Its focus was to evaluate the improvement in the accessibility of specific strategies reported by each centre, after participating in this QIC, and working to implement change within their own PEDs. Results: All 15/15 Canadian PEDs responded to the TRAPPED 1 survey in 2013 and 11 agreed to participate in the national pain QIC. In-person, phone meetings, follow up surveys and email communications were employed for information sharing. Strategies identified by the QIC to be newly introduced in individual centres were educational initiatives, distraction options, nurse-initiated protocols and intranasal (IN) medications. All 15 PEDs completed the TRAPPED 2 survey. Compared to 2013, an increased number of PEDs used face-based pain scales (14/15 vs 6/15) and behavioural scales (5/15 vs 1/15) for pain assessment in 2015. Use of reminder posters on pain management at triage increased from 4/15 to 6/15 PEDs. Availability of tablets for distraction increased from 4/15 to 10/15 PEDs. Nurse-initiated protocols for topical anesthetic and oral sucrose (for needle procedures) increased from 10/15 to 12/15 sites and from 12/15 to 14/15 sites respectively. Availability of IN medications increased; fentanyl from 9/15 to 14/15 sites and midazolam from 8/15 to 10/15 sites. Ten of the 11 PEDs involved in the QIC strategy reported the implementation of at least one of their own identified strategies. Conclusion: This study suggests that the use of a QIC may improve the introduction of new strategies to reduce pain and anxiety in EDs. QICs may also be helpful to other centres when introducing new strategies.