Practice-Change Pathway to Reduce Procedural Distress During Intussusception Reduction-A Quality Improvement...

Intussusception is a medical emergency requiring reduction with a pneumatic or hydrostatic enema. Although evidence supports the safety of medications to reduce distress during the procedure, their use remains limited. This quality improvement (QI) project aimed to provide analgesic and anxiolytic medications to all eligible patients undergoing pneumatic reduction within 1 year.

A multidisciplinary team developed a standardized clinical pathway to provide both intranasal fentanyl and midazolam for all patients undergoing intussusception reduction. The interventions included staff education, team engagement, and process interventions through sequential Plan-Do-Study-Act cycles. The primary outcome measure was pathway provision. Process measures included documentation of pain and sedation scores, while balancing measures assessed adverse events, failed reductions, and perforation rates.

Over the project period, 25 patients were diagnosed with intussusception. Two patients with lead points proceeded directly to surgery. Among the 23 patients with planned pneumatic reduction, 19 (82%) had successful reductions, 2 had spontaneous reductions, and 2 required surgical intervention due to failed reductions. Pathway provision improved from 0% at baseline to 100% by the project's end. Pain score documentation reached 100%. No cases of serious adverse events or intestinal perforation were reported. Pathway compliance remained at 100% during the sustainment period. The interval number of days between patients who did not receive analgesia and anxiolysis was short initially but progressively lengthened.

This QI initiative improved rates of analgesic and anxiolytic provision to reduce distress in patients undergoing intussusception reduction, without adverse outcomes. This project highlights the effectiveness of structured interventions in optimizing pediatric procedural pain management and potentially serves as a model for spread to other pediatric emergency departments.