Application of Clinical Microsystems Improves the Speed of the Initial Pain Relief in Sickle Cell Disease (SCD) Patients Admitted with Acute Vaso-Occlusive Crisis (VOC)

The management of acute vaso-occlusive crisis continues to be a challenge in patients with sickle cell anemia. Long Island Jewish Medical Center is a 500 adult bed, tertiary care facility, with more than 500 reported admissions for acute vaso-occlusive crisis in 2009. Suboptimal pain management in the Emergency Department (ED) frequently resulted in unrelieved pain, recurrent admissions, prolonged hospitalization, and increased patient dissatisfaction.

An interdisciplinary team which included a patient with SCD was assembled to meet weekly to address the above issues. The team was educated in Clinical Microsystem methods as described by Nelson et.al (1) over 6 months. Preliminary data was collected to assess performance with respect to pain management in adult SCD patients presenting to the ED through pain diaries. The admission process was analyzed and significant delays were noted from time of presentation to the time that sufficient sustained analgesia was achieved. The PDSA (Plan Do Study Act) cycle method to test and study change was utilized. The specific aim was to achieve a sustained 2 point reduction in subjective pain score within 2 hours of inpatient admission. Four interventions were simultaneously tested. First, given the high frequency of admission from our ED for this patient population, we tested proactive bed designation initiated when the patient presented to the ED. Second, we educated the housestaff on providing appropriately dosed narcotic administration upon admission after pharmacy verification of previous patient specific dose requirements. Third, we arranged expedited transfer to the medical floors for these patients. Lastly, we arranged for storage of PCA pumps on the medical unit designated for SCD patients, facilitating immediate initiation of pain medication via this modality. Timing of analgesic response was assessed based on patient interviews and the above mentioned diaries.

During the pre-intervention stage it took an average of 55 hours and 20 minutes to achieve a sustained reduction in pain by two points. Post intervention, the team achieved a sustained 2 point reduction in subjective pain score by an average of 9 hours and 58 minutes (see figure).

The Clinical Microsystems Methodology is an effective means of engaging an interdisciplinary team in improving the initial analgesic response to treatment in sickle cell patients admitted with acute vaso-occlusive crisis.

No relevant conflicts of interest to declare.