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Background: Orthopedic complaints are one of the most frequent reasons for presentations to the pediatric emergency department (PED). National metrics have defined that each child should have a pain assessment and/or pain medication administered within one hour of arrival to an emergency department. Patient surges, transfers from referring hospitals, and acuity can affect the ability of a PED to meet this metric. Objective: To implement a quality improvement process to ensure children presenting to a PED receive a pain assessment and pain medications within one hour of arrival. Methods: We queried our electronic medical record (EMR) for all patients presenting to our level 1 trauma center PED pain for the 90 days prior to implementation and then for the 90 days post implementation of the quality improvement process. The bundle included nursing, support staff, and physician education to quickly identify children with long bone pain then calling the designated physician carrying the “bone phone.” The physician carrying the bone phone then had 15 minutes to complete an assessment, order pain medication and radiographs and document these interventions in the EMR. Results: During the study period, 553 total fractures were identified with 337 long bone fractures that met inclusion criteria (61%). Of these fractures, 105 required casting and 82 fractures required reduction in the PED, 127 necessitated OR repair, and 23 had a different outcome. Our pre-intervention average time to pain medication was 63 minutes and our time to medication ordered was 45 minutes. Our post-intervention average time to pain medication was 55 minutes and our time to medication ordered was 38 minutes. Conclusions: Our intervention bundle was successful in reducing our time to assessment and time to pain medication administration. Future studies will look at using template orders and chief complaint driven nursing order sets to further reduce the time to pain medication administration for long bone pain patients. Future studies will also benefit from exploring if opiophobia contributes to delayed pain medication administration in the pediatric emergency department.

The Bone Phone: Improving Time to Pain Medication Administration in Long Bone Patients