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Applying Topical Anesthetic on Pediatric Lacerations in the Emergency Department: A Quality Improvement Project
Nagham Faris1, Mohamad Mesto, Sandra Mrad
1From the Department of Emergency Medicine, The American University of Beirut, Beirut, Lebanon.
Insights
Applying topical anesthetic, Eutectic Mixture of Local Anesthetics (EMLA), to pediatric lacerations in the emergency department significantly increased from 23% to 60%. This improvement in pain management was sustained, enhancing patient care during laceration treatment.
Area of Science:
- Emergency Medicine
- Pediatric Care
- Pain Management
Background:
- Pediatric laceration treatment in the ED is often painful due to irrigation and suturing.
- Current use of topical anesthetics like Eutectic Mixture of Local Anesthetics (EMLA) for eligible pediatric lacerations is low (23%).
Purpose of the Study:
- To increase the application rate of EMLA for eligible pediatric lacerations to a goal of 60%.
- To achieve a sustainable and measurable improvement in pain management for pediatric lacerations in the ED.
Main Methods:
- A prospective, single-center, interrupted time series quality improvement project was conducted.
- Key interventions included early EMLA placement and physician engagement through Plan, Do, Study, Act (PDSA) cycles.
- Data collection involved patient and physician feedback, with balancing measures assessing ED length of stay and satisfaction.
Main Results:
- Three PDSA cycles successfully increased EMLA application to the 60% goal within 3 months, maintained for 5 months.
- Patient satisfaction with EMLA was high (75%), with no reported adverse events.
- A slight increase in ED length of stay was observed for patients receiving EMLA compared to those who did not.
Conclusions:
- Simple interventions effectively increased and sustained the use of EMLA for pediatric lacerations in the ED.
- The study demonstrates a successful quality improvement initiative for pediatric pain management.
Objectives:
Caring for pediatric lacerations in the emergency department (ED) is typically painful because of irrigation and suturing. To improve this painful experience, we aimed to increase the use of a topical anesthetic, Eutectic Mixture of Local Anesthetics (EMLA) on eligible pediatric lacerations with an attainable, sustainable, and measurable goal of 60%. The baseline rate of applying topical anesthetic to eligible lacerations was 23% in our ED. We aimed to increase the use of topical anesthetics on eligible pediatric lacerations to a measurable goal of 60% within 3 months of implementing our intervention.
Methods:
We conducted a prospective, single-center, interrupted time series, ED quality improvement project from November 2019 to July 2020. A multidisciplinary team of physicians and nurses performed a cause-and-effect analysis identifying 2 key drivers: early placement of EMLA and physician buy-in on which we built our Plan, Do, Study, and Act (PDSA) cycles. We collected data on number of eligible patients receiving EMLA, as well as patient and physician feedback via phone calls within 2 days after encounter. Balancing measures included ED length of stay (LOS), patient and physician satisfaction with EMLA, and adverse effects of EMLA.
Results:
We needed 3 PDSA cycles to reach our goal of 60% in 3 months, which was also maintained for 5 months. The PDSA cycles used educational interventions, direct provider feedback about noncompliance, and patient satisfaction results obtained via phone calls. Balancing measures were minimally impacted: 75% good patient satisfaction, no adverse events but an increase in LOS of patients who received EMLA compared with those who did not (1.79 ± 0.66 vs 1.41 ± 0.83 hours, P < 0.001). The main reasons for dissatisfaction for physicians were the increased LOS and the preference for procedural sedation or intranasal medications.
Conclusions:
With a few simple interventions, our aim of applying EMLA to 60% of eligible pediatric lacerations was attained and maintained.
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