LO22: Improving the pain experience for children with limb injury: a city-wide quality improvement collaborative
Authors: Thull-Freedman J. , Williamson T. , Pols E. , McFetridge A. , Libbey S. , Lonergan K. , Lang E. , Stang A. 
Published: May 2018

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.