Background Systematic literature reviews show a paucity of publications describing the sustainability of quality improvement (QI) outcomes beyond one year. Hence, sustainability is not well understood, particularly in relation to ongoing improvement work and process changes in clinical care environment.

Objectives To evaluate the sustainability of an improved outcome resulting from a QI intervention to provide timely intravenous opioid delivery to patients with long bone fractures in a pediatric emergency department (PED) despite a dynamic QI environment. The initial QI intervention was implemented October 2007.

Methods The primary outcome was the proportion of patients with long-bone fractures receiving intravenous opioids within 45 minutes of arrival to an urban tertiary PED setting. Retrospective visit level data from 1/2007 through 6/2014 were obtained from the electronic health record. table 1 summarizes PED process changes implemented after the initial QI intervention. The effects of process changes on the primary outcome were determined using a monthly control chart (p-chart) and an interrupted autoregressive time series model.

Results Overall, improvement in the proportion of patients receiving timely intravenous opioids has been sustained for seven years since the initial implementation (figure 1). The p-chart, which is further supported by the results from the interrupted time series analysis (table 2), shows special cause variation attributable to two additional process changes related to physician responsibilities and staffing.

Conclusions Our initial improvement gains were robust despite multiple process changes in the care environment. Changes in physician staffing and physician responsibilities in a PED may be especially important to consider for future improvement initiatives.⇓⇓⇓

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Figure 1

Patients with Acute Long Bone Fractures Who Received a dose of iv Opioid within 45 minutes of Arrival January 2007 thru june 2014.