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BACKGROUND: Multiples barriers to appropriate analgesia provision are reported in the paediatric emergency department (PED), including limited accessibility to effective strategies. OBJECTIVES: To evaluate the improvement in the accessibility of pain and anxiety management strategies in PEDs in Canada, after the creation of a national pediatric pain quality improvement collaborative, through Pediatric Emergency Research Canada. DESIGN/METHODS: In 2013, the TRAPPED 1 survey was administered across Canadian PEDs, in order to evaluate the resources in place for pain and anxiety management. Subsequent to the TRAPPED 1, a pain Quality Improvement Collaborative was created to stimulate the implementation of new pain and anxiety management strategies through the sharing of information between PEDs. The TRAPPED 2 survey involved a cross sectional survey similar to TRAPPED 1, after a two year interval. Its main focus was to evaluate the improvement in the accessibility of specific, preferred strategies reported by each centre, after participating in this collaborative between December 2014 to November 2015, and then working to implement change within their own PEDs. RESULTS: All 15/15 Canadian PEDs responded to TRAPPED 1 in 2013. In 2014, 11/15 agreed to participate in the national pain Quality Improvement Collaborative, with a goal of introducing new pain and anxiety management strategies within their own PEDs. An in-person meeting, email communication, and telephone meetings were employed for information sharing regarding experiences/challenges within each of the participating centres. Newly introduced strategies included education, distraction, nurse-initiated protocols, and policies/education to encourage the use of intranasal (IN) medications. 11/11 centres have responded to the interim follow up surveys in 2015. At the end of the project (Fall 2105), 15/15 Canadian PEDs agreed to complete the final TRAPPED 2 survey. When comparing the results of 2015 with 2013, an increased number of PEDs used face-based pain scales (14/15 vs 6/15) and behavioural scales (5/15 vs 1/15) for pain assessment of school-aged children and infants, respectively. Use of assessment room wall decoration for distraction increased from 7/15 to 11/15. Reminder posters for pain management at triage increased from 4/15 to 6/15. Availability of electronic distraction strategies (e.g. using tablets) increased from 4/15 to 10/15 centres. For skin-piercing procedure, nurses initiated protocols to use topical anesthetic creams and oral sucrose was available in 12/15 centres (compared to 10/15 in 2013), and 14/15 (compared to 12/15 in 2013) respectively. Availability of IN medications increased in the last two years: fentanyl 14/15 (9/15 in 2013) and midazolam in at least 10/15 (8/15 in 2013). 10/11 PEDS involved in the QI strategy reported the implementation of at least one of their strategies identified. CONCLUSION: This study suggests that the use of a pain Quality Improvement Collaborative may improve the introduction of new strategies in multiple PEDs. It can help guide other centres when introducing new strategies to reduce pain and anxiety for children in community EDs. Future research can focus on the sustainability of the strategies, and as well the effect of the collaborative on the introduction of other pain treatment strategies.

BACKGROUND: Recently, intranasal (IN) fentanyl and inhaled nitrous oxide/oxygen (N2O) mixture have been increasingly used for procedural sedation and analgesia (PSA) alone or in combination. There is a lack of data on the efficacy of these combined agents. OBJECTIVES: To evaluate the efficacy of IN fentanyl and N2O as PSA for the reduction of mildly-to-moderately displaced fractures and dislocations. DESIGN/METHODS: We performed a prospective, observational cohort study between September 2014 and October 2015. Patients were recruited at CHU Sainte Justine (Montréal, Canada) and Royal Children Hospital (Melbourne, Australia). Patients between the age of 4 and 18 years were eligible if PSA consisted of IN fentanyl and N2O for the reduction of mildly-to-moderately displaced fractures or dislocations. Patients received at least IN fentanyl 1.5 mcg/kg (100 mcg max) and at least a 50/50% mixture of N2O with oxygen. Primary outcome was the efficacy of PSA measured by the patient assigned Facial Pain Scale-Revised (FPS-R). The Face, Legs, Activity, Cry, Consolability (FLACC) scale was also recorded. Depth of sedation was evalu-ated using the University of Michigan Sedation Scale (UMSS). Adverse events were recorded following the criteria of the Consensus Panel on Sedation Research of PERC/PECARN. Additional data concerning satisfaction or discomfort were evaluated via questionnaires, and follow-up telephone calls were made to elicit information on adverse events after discharge. RESULTS: A total of 91 patients aged 9.7±3.0 years were enrolled. There was no difference between the median FPS-R score during the procedure compared to before: Median 2 and 2 (median difference 0 [95% CI 0, 0]), respectively. The FLACC score was higher during the procedure than before: Median 4 and 0 (median difference 2 [95% CI 1, 3]). UMSS was 1 (95% CI 1, 2) during the procedure. 42 (46%) patients had adverse events, all mild: vertigo (20%), nausea (16%)]or vomiting (12%). A total of 85/88 (97%) parents and 82/85 (96%) ED physicians would want the same sedation in another procedure. CONCLUSION: PSA with IN fentanyl and N2O seems effective in our cohort study, as evaluated by patient assigned FPS-R. Patients were minimally sedated. Adverse events were frequent but mild. Overall, parents and medical staff would want the same agents used in another procedure. Thus, PSA with IN fentanyl and N2O appears to be an attractive option for reduction of mildly displaced fractures or dislocations.