Quality Improvement Goals for Sickle Cell Disease Pain Management in an Urban Pediatric Emergency Department: We Can Do Better!.

Abstract

AbstractAbstract 2101▪▪This icon denotes a clinically relevant abstract Background.Vaso-occlusive painful episodes (VOE) are the leading cause of hospitalizations and emergency department (ED) visits in sickle cell disease (SCD), and are associated with increased mortality. Although disparities specific to pain management practices in the ED for children with SCD have not been identified, ethnic disparities in ED care have been reported, & adults with SCD experience longer delays in the initiation of analgesics compared to other patients with pain. However, initiation of treatment in the ED is often delayed as a result of random events that are beyond anyone’s control, such as high patient volumes & acuity of other patients in the ED, even when policies are in place for immediate triage of patients with SCD & pain. In a recent study of children with SCD, median time from arrival to analgesia administration was 90 minutes, with high ED census as the biggest culprit for delays. Barriers to rapid care in the ED are common across the country, including overcrowding, nursing ratios, insufficient staff coverage, inadequate funding, & slow flow of patients from the ED to the wards in addition to patient acuity. Methods.As part of a quality improvement (QI) project to improve management of SCD pain in the ED at Children’s Hospital & Research Center Oakland, we are reviewing quality indicators to determine areas that can be targeted for improvement. ED-based data was collected and analyzed from a sample of 47 patients initially evaluated in the ED and enrolled in a randomized, placebo-control trial of argininetherapy for children with SCD hospitalized for VOE between years 2000–2008, and compared to recent data in 2012 of 55 ED visits for VOE (66% admissions) to identify trends in practice in our ED. Results.See Table 1. Conclusions.To these authors' surprise, children with SCD commonly experienced delays in pain management in the ED. These trends have not changed dramatically over a decade, and are not likely to be unique to our facility. Areas to target for improvement include time of arrival to parenteral pioid administration, in particular, time from ED room placement to placement of intravenous catheter. Utilizing intranasal fentanyl in the ED for acute pain is one novel intervention that should significantly decrease time to initial pain management. These reported data will be used as baseline quality measures for comparison to determine the success of QI initiatives such as a refined pain management algorithm on ED-based clinical outcomes.Table 1Arginine study (N=47) 2000-2008QI review (N=55) 2012Age (SD)13.9±414.5±6Gender, N (%)Male23 (49%)18 (33%)Female24 (51%)37 (67%)Diagnosis, N (%)Hb-SS33 (70%)41 (74.5%)Hb-SC9 (19%)14 (25.5%)Hb-Sickle β-thalassemia5 (11%)0 (0%)HU Use N (%)11 (23%)21 (38%)Triage to 1st Opioid dose ±SD (min)111±11496±41Triage to Room21±4812±13Room to IV Placement77±10273±46IV Placement to 1st Opioid Dose29±4217±261st Narcotic Dose to 2nd Opioid Dose124±8677±62ED Length of Stay±SD (hrs)5.4±2.75.6±2.25% Admissions100%65.5%Total Length of Hospital Stay±SD (days)4.5±2.53.4±2.3% IV Opioid given in < 30 min15%3%% 30–60 min11%13%% 60–120 min28%55%% IV Opioid given > 2 hours23%24%No IV Opioid (oral only/IV ketorolac)23%5% Disclosures:No relevant conflicts of interest to declare.