Despite its high prevalence, pain often is poorly managed in the emergency department. We used improvement science and quality-improvement methods to reduce delays associated with opioid delivery for children presenting to the emergency department with clinically apparent extremity fractures.


On the basis of a review of the literature, interviews with key stakeholders, expert consensus, and reviews of isolated examples of patients receiving timely analgesics, a multidisciplinary improvement team identified a set of operational factors, or key drivers, believed to be critical to the performance of appropriate initial pain management for children presenting to the emergency department with acute extremity injury. These key drivers focused the development of an intervention.


The intervention, termed the orthopedic evaluation process, addressed all 4 identified key drivers simultaneously by standardizing triage decisions, activating necessary health care providers, aligning the care delivery need with necessary resources, and allowing parallel-task completion between physicians and nursing staff. After implementation of this process, 95% of the patients with long-bone extremity fractures treated with intravenous opioids received a first dose within 45 minutes of arrival, compared with a preintervention baseline average of 20%.


By applying quality-improvement and process improvement methodology, we identified key drivers for the rapid delivery of systemic opioids to patients with clinically apparent extremity fractures and significantly improved the timeliness of analgesic delivery for this subgroup of patients.

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