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Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative
  1. Mariann Nocera Kelley1,2,
  2. Willliam Lynders2,3,
  3. Emily Pelletier3,
  4. Megan Petrucelli2,3,
  5. Beth Emerson4,
  6. Gunjan K Tiyyagura4,
  7. Michael Paul Goldman2,4
  1. 1 Division of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine/Traumatology, University of Connecticut School of Medicine, Connecticut Children's Hospital, Hartford, Connecticut, USA
  2. 2 Emergency Medical Services for Children, Connecticut, New Haven, Connecticut, USA
  3. 3 Emergency Medicine, Middlesex Health, Middletown, Connecticut, USA
  4. 4 Department of Pediatrics and the Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  1. Correspondence to Dr Mariann Nocera Kelley; Mkelley{at}


Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these gaps using quality improvement (QI) methodology. Project champion from a community hospital network identified the use of safe pharmacological and non-pharmacological anxiolysis and analgesia (A&A) as one such gap and partnered with EMSC to address it. Our primary Specific, Measurable, Achievable, Relevant and Time-Bound (SMART) aim was to increase intranasal midazolam (INM) use for common, anxiety-provoking procedures on children <8 years of age from 2% to 25% in a year.

EMSC facilitated a QI team with representation from the CED and regional children’s hospitals. Following the model for improvement, we initiated a process analysis of this CED A&A practice. Review of all paediatric procedural data identified common anxiety-provoking simple procedures as laceration repairs, abscess drainage and foreign body removal. Our SMART aims were benchmarked to two regional PEDs and tracked through statistical process control. A balancing metric was ED length of stay (ED LOS) for patients <8 years of age requiring a laceration repair. Additionally, we surveyed CED frontline staff and report perceptions of changes in A&A knowledge, attitudes and practice patterns. These data prioritised and informed our key driver diagram which guided the Plan-Do-Study-Act (PDSA) cycles, including guideline development, staff training and cognitive aids.

Anxiety-provoking simple procedures occurred on average 10 times per month in children <8 years of age. Through PDSA cycles, the monthly average INM use increased from 2% to 42%. ED LOS was unchanged, and the perceptions of provider’s A&A knowledge, attitudes and practice patterns improved.

A CED-initiated QI project increased paediatric A&A use in a CED network. An A&A toolkit outlines our approach and may simplify spread from academic children’s hospitals to the community.

  • analgesia
  • pediatric emergency medicine
  • pediatrics
  • quality improvement
  • pain management

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  • Handling editor Edward Carlton

  • Contributors GKT were integral in conception and design of the work, data analysis and interpretation, drafting the article, critical revision of the article and final approval of the manuscript. WL, EP and MP were involved in conception and design of the work, data collection, analysis and interpretation, drafting the article, critical revision of the article and final approval of the manuscript. BE and GKT were integral in data analysis and interpretation, critical revision of the article and final approval of the manuscript.

  • Funding This study was supported by Emergency Medical Services for Children (EMSC), a federally funded programme that awards state teams funding towards work on improving paediatric readiness in the community setting, through the use of EMSC personnel and expertise resources only. No financial resources were provided for this study. None of the authors have any financial support or sponsorship to declare.

  • Competing interests None declared.

  • Patient and public involvement statement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.