Intranasal Fentanyl and Quality of Pediatric Acute Care

J Emerg Med. 2017 Nov;53(5):607-615.e2. doi: 10.1016/j.jemermed.2017.05.027. Epub 2017 Sep 28.


Background: Changes in the manner in which medications can be delivered can have significant effects on the quality of care in the acute care setting.

Objective: The objective of this study was to evaluate the change in three Institute of Medicine quality indicators (timeliness, safety, and effectiveness) in the pediatric emergency department (ED) after the introduction of the Mucosal Atomizer Device Nasalâ„¢ (MADn) for opioid analgesia.

Methods: This was a retrospective review of patients receiving opioid analgesia for certain conditions over a 5-year period. We compared patients receiving intravenous opioid (IVO) to those receiving intranasal fentanyl (INF). Timeliness outcomes include time from medication order to administration, time from dose to discharge, overall time to analgesia, and ED length of stay. Effectiveness outcomes include change in pain score and frequency of repeat dosing. Safety outcomes were the frequency of reversal agent administration or a documented oxygen desaturation of < 90%. Sensitivity analyses were performed to evaluate the effect of moderate sedation on all three outcomes.

Results: During the study period, 1702 patients received opioid analgesia, 744 before and 958 after MADn introduction, of whom, 233 (24%) received INF. After MADn introduction, patients receiving INF had a shorter time to discharge from dose (109 vs. 203 min; p < 0.05) and shorter ED length of stay (168 vs. 267 min; p < 0.05). There was no difference in pain score reduction; however, repeat dosing was less frequent for patients receiving INF (16% vs. 27%). There was no use of reversal medication and no difference in the frequency of oxygen desaturations. When patients undergoing moderate sedation were removed from the analysis, there was no difference in the direction of findings for all three outcomes.

Conclusions: INF is associated with improved timeliness and equivalent effectiveness and safety when compared to IVO in the setting of the pediatric ED.

Keywords: analgesia; pediatric emergency department; quality domains.

MeSH terms

  • Administration, Intranasal / standards*
  • Administration, Intravenous / standards*
  • Adolescent
  • Analgesics, Opioid / administration & dosage
  • Analgesics, Opioid / therapeutic use
  • Child
  • Child, Preschool
  • Female
  • Fentanyl / administration & dosage*
  • Fentanyl / therapeutic use
  • Humans
  • Infant
  • Male
  • Pain / drug therapy
  • Pain Management / methods
  • Pain Management / standards
  • Pediatrics / methods
  • Pediatrics / standards*
  • Quality of Health Care / standards*
  • Retrospective Studies
  • Time Factors


  • Analgesics, Opioid
  • Fentanyl