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Evaluating the Implementation Barriers of an Intranasal Fentanyl Pain Pathway for Pediatric Long-Bone Fractures
Tamara Arnautovic, Kathryn Sommese1, Paul C Mullan2
1Department of Pediatrics, Eastern Virginia Medical School.
Insights
Despite an intranasal fentanyl (INF) pathway, 41% of pediatric long-bone fracture patients missed opportunities for INF pain management. Physician preference for IV morphine presents a barrier to INF utilization in the emergency department.
Area of Science:
- Pediatric Emergency Medicine
- Pain Management
- Pharmacology
Background:
- Intranasal fentanyl (INF) offers a non-invasive option for pediatric pain management.
- Establishing effective pain management pathways in pediatric emergency departments (EDs) is crucial.
Purpose of the Study:
- To evaluate physician comfort, knowledge, and barriers to using intranasal fentanyl (INF) for long-bone fractures in a pediatric ED.
- To assess the implementation and utilization of an established INF pain pathway.
Main Methods:
- Retrospective chart review of 1374 pediatric patients (3-21 years) with long-bone fractures.
- Categorization into groups based on INF pathway adherence, missed opportunities, IV establishment, or no medication.
- Physician survey to identify barriers to INF pathway utilization.
Main Results:
- 41% of eligible patients experienced missed opportunities for INF administration.
- Physician surveys indicated greater comfort and preference for intravenous morphine over INF.
- No association found between patient age or physician experience and missed opportunities.
Conclusions:
- A high rate of missed opportunities highlights significant barriers to the effective implementation of the INF pain pathway.
- Further research is needed to understand and address physician-related barriers to INF utilization.
Objectives:
This study aimed to assess physician comfort, knowledge, and implementation barriers regarding the use of intranasal fentanyl (INF) for pain management in patients with long-bone fractures in a pediatric emergency department (ED) with an INF pain pathway.
Methods:
A retrospective chart review was conducted of patients, 3 to 21 years old, in our ED with an International Classification of Diseases-9th Revision code for a long-bone fracture from September 1, 2013, to August 31, 2015. Patients were divided into 4 groups: (1) received INF on the pathway appropriately; (2) "missed opportunities" to receive INF, defined as either INF was ordered and then subsequently canceled (for pain ratings, ≥6/10), or INF was ordered, cancelled, and intravenous (IV) morphine given, or INF was not ordered and a peripheral IV line was placed to give IV morphine as first-line medication; (3) peripheral IV established upon ED arrival; (4) no pain medication required. Additionally, a survey regarding practice habits for pain management was completed to evaluate physician barriers to utilization of the pathway.
Results:
A total of 1374 patients met the inclusion criteria. Missed opportunities were identified 41% of the time. Neither younger patient age nor more years of physician experience in the ED were associated with increased rates of missed opportunities. The survey (95% response rate) revealed greater comfort with and preference for IV morphine over INF.
Conclusions:
The high rate of missed opportunities, despite the implementation of an INF pain pathway, indicates the need for further exploration of the barriers to utilization of the INF pain pathway.
