PC1035: Evidence-based Standardization of Migraine Management in the Pediatric Emergency Department: A Quality Improvement Project

Purpose/Objectives: Migraine headaches are a common complaint in patients presenting to the pediatric emergency department (PED). Interventions to treat migraine headaches range from non-pharmacologic support to intravenous (IV) medications. We identified significant variation in the management of patients with migraine headaches presenting to our PED.

The primary aim of this quality improvement (QI) project was to increase physician adherence to an evidence-based guideline for migraine treatment from 38% to 50% within 6 months. The secondary aim was to increase the proportion of patients with a 50% reduction in pain score or a pain score less than 4 at the time of discharge by 10%, from 72% to 82% within 6 months.

Design/Methods: Our multidisciplinary team, including PED and neurology physicians, PED nursing, and pharmacy, reviewed the current literature and developed an evidence-based, standardized treatment guideline for migraine headaches. Treatment is divided into oral (PO) and IV bundles based on the patient’s initial pain score, with all patients receiving non-pharmacologic support. The PO treatment bundle includes a triptan and non-steroidal anti-inflammatory drug, while the IV treatment bundle includes ketorolac, prochlorperazine, diphenhydramine, and a normal saline bolus. Valproate sodium is recommended for secondary IV treatment of refractory migraine and dihydroergotamine is reserved for tertiary IV treatment in consultation with neurology. A key driver diagram was created to identify key drivers and interventions including early identification and treatment of migraine, an order set within the electronic medical record, and physician and nursing education. The primary measure was PED physician adherence to the evidence-based guideline and the outcome measure was pain score reduction. Balancing measures included ED length of stay, return visits to the PED within 48 hours, and inpatient admissions. We used statistical process control to analyze changes in measures over time.

Results: Physician adherence to the evidence-based guideline increased from 38% to 70% (Figure 1). The proportion of patients that achieved a pain score less than 4 or a 50% reduction in pain score at the time of discharge increased from 72% to 89% (Figure 2). ED Length of stay, return visits within 48 hours, and inpatient admissions did not increase.

Conclusion/Discussion: Using QI methodology, PED physician adherence to an evidence-based guideline for migraine treatment increased and the proportion of patients with a 50% reduction in pain score or a pain score less than 4 at time of discharge improved. Future interventions include incorporating shared decision-making regarding PO versus IV medications for patients who present with moderate pain, continued nursing education on timely pain score reassessments, and additional physician education and training.