Evaluating the Implementation Barriers of an Intranasal Fentanyl Pain Pathway for Pediatric Long-Bone Fractures Tamara Arnautovic, MD, MHS,* Kathryn Sommese, MS,† Paul C. Mullan, MD, MPH,‡ Steven Barron Frazier, MD,§ Turaj Vazifedan, MS,‡ and Dana Erikson Ramirez, MD‡ 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, de- fined as either INF was ordered and then subsequently canceled (for pain ratings, ≥6/10), or INF was ordered, cancelled, and intravenous (IV) mor- phine 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 oppor- tunities were identified 41% of the time. Neither younger patient age nor more years of physician experience in the ED were associated with in- creased rates of missed opportunities. The survey (95% response rate) re- vealed greater comfort with and preference for IV morphine over INF. Conclusions: The high rate of missed opportunities, despite the imple- mentation of an INF pain pathway, indicates the need for further explora- tion of the barriers to utilization of the INF pain pathway. Key Words: intranasal, fentanyl, pain, morphine, physician (Pediatr Emer Care 2017;00: 00–00) P ain is the most common presenting symptom in the emergency department (ED), and pain management in the pediatric popu- lation is often suboptimal. 1,2 Pain control in pediatric patients with orthopedic trauma in the ED is often undertreated. 3,4 Providing a more efficient solution to pain relief in the setting of pediatric orthopedic trauma is a priority recognized by the American Acad- emy of Pediatrics in their policy statement on eliminating pain- associated suffering within the medical setting. 5 Despite this policy, barriers to adequate pain management in pediatrics persist, includ- ing a fear of prescribing opioids to children, lack of formal training regarding opioid medication choice, fear of causing adverse drug reactions, difficulty of communicating pain levels by pediatric pa- tients, and provider discomfort ordering opioids for children. 6–9 Although intravenous (IV) morphine is fast and effective, pe- ripheral IV (PIV) placement can be challenging in the pediatric population. 10 Peripheral intravenous placement has also been well described as one of the most painful and anxiety-provoking expe- riences in a patient’s ED visit. 11,12 Intranasal (IN) fentanyl has been proven to be equally effective as IV morphine for rapid pain relief of pediatric long-bone fractures (LBFs). 12 Intranasal fenta- nyl also enables a faster, less invasive method of pain medication delivery, because no PIV placement is needed. 8,9,13 Multiple stud- ies have described the benefits of using IN fentanyl for pain man- agement in the ED setting. 11,14,15 However, studies have shown that the translation of research-based evidence into clinical prac- tice takes an average of 17 years. 16 The Institute for Healthcare Improvement highlights this knowledge translation as a key barrier to effective health care improvement. The use of IN fen- tanyl for pain management in the pediatric ED has been slower than expected, with many ED providers still focusing on IVopioid treatment as first-line therapy. 17–19 To our knowledge, there is no current literature describing pediatric ED physician bariers to using IN fentanyl. 2,8 In 2011, the Children’s Hospital of The King’s Daughters Emergency Department (CHKD-ED) implemented an IN fentanyl pain clinical pathway for LBFs and demonstrated that the utiliza- tion of the pathway significantly decreased time to pain medication administration and demonstrated equal efficacy as IV morphine. 11 In the year after the implementation of this new pathway (Appendix 1, http://links.lww.com/PEC/A225), we anecdotally noted significant underuse of IN fentanyl for patients with suspected diagnoses of LBFs who did not have IV access. This study aims to assess phy- sician comfort, knowledge, and implementation barriers regarding the use of parenteral opioids for pain management in a pediatric ED. We hypothesized that years of experience in the pediatric ED setting will be inversely correlated with IN fentanyl use for pediatric LBFs, as more years in practice as a physician has been associated with slower adaption of new practices 20–23 Furthermore, we hy- pothesized that younger patient ages would receive IN fentanyl less frequently, because younger age has been described as a bar- rier for using opioids in other pediatric studies. 24–27 METHODS Study Design and Setting We conducted a retrospective chart review in the ED of an ur- ban academic children’s hospital that sees approximately 50,000 patient visits per year. Additionally, an anonymous electronic survey was administered to physicians working in the CHKD-ED. This study was approved by our institutional review board. Selection of Participants We performed a chart review of all patients between 3 and 21 years of age (to correspond with the ages eligible for placement on our IN fentanyl pain pathway), presenting to the CHKD-ED with an International Classification of Diseases-9th Revision code for a From the *Department of Pediatrics, Hasbro Children's Hospital, Alpert Medi- cal School of Brown University, Providence, RI; †Department of Pediatrics, Eastern Virginia Medical School; ‡Department of Pediatrics, Division of Emer- gency Medicine, Children's Hospital of the King's Daughters, Norfolk, VA; and §Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN. Disclosure: The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.pec-online.com). Reprints: Paul Christopher Mullan, MD, MPH, 601 Children's Lane, Norfolk, VA, 23507 (e‐mail: mullan20@gmail.com). Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 ORIGINAL ARTICLE Pediatric Emergency Care • Volume 00, Number 00, Month 2017 www.pec-online.com 1 Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.