Improving Medication Timeliness in Pediatric Sickle Cell Disease Population Presenting to the Emergency Department with Vaso-Occlusive Episode

Background: Vaso-occlusive episode (VOE) is the most common acute complication for individuals with sickle cell disease (SCD) and most common reason to seek medical care. Rapid initiation of analgesia therapy, with timely subsequent doses as needed upon presenting to the emergency department (ED) for VOE are current established guidelines. Our center's initial analgesic approach aligns with NHLBI Guidelines of initial analgesic therapy within 60 minutes of registration and reassessment along with subsequent doses every 15 to 30 minutes if severe pain persists. Our center also recommends initiation of continuous infusion (CI) of pain medication within 60 minutes following third bolus dose of pain medication for those not achieving sufficient analgesia.

Objective: This project's aim is to reduce time to initial dose of analgesic therapy in patients with SCD presenting to the ED with VOE to less than 60 minutes from registration in 90% of study population, decrease time interval between first and third dose of opioids to less than 60 minutes in 90% of study population, and initiate CI of pain medication within 60 minutes of third dose of opioids in 75% of individuals requiring further analgesic support. The goal is to achieve these measures within the completion of 6 monthly Plan-Do-Study-Act (PDSA) cycles.

Methods: Three initial countermeasures were implemented within our institution to achieve the targeted objectives. (1) An adjustment to current ED order sets was made to include intranasal fentanyl as an initial one time option for a quicker analgesic option upon registration. (2) Another adjustment was made to the initial ED order set used upon presentation of the patient to include CI orders instead of the current system of having separate order sets for initial bolus dosing of analgesic therapy and CI order. (3) Final initial adjustment was made to change nursing prompt within the electronic medical record (EMR) for reassessment following bolus doses of pain medication; prompts were changed to every 20 minutes from every 30 minutes for the nurses with idea to better target goal of <30 minutes between doses for those who are in persistent severe pain.

Results: Baseline data was obtained by retrospective chart review over a three month period. A median of 58.8% of patients were receiving an initial dose of analgesic therapy within 60 minutes of registration. Sixty minutes between first and third dose occurred in 53.8% of patients. Initiation of CI was occurring in 8.3% of patients within 60 minutes of the third dose of opioids.

Over the first PDSA cycle, improvement has been noted across all 3 aims. For the initial dosing, 68% of patients were receiving within 60 minutes. Time between first and third dosing of less than 60 minutes occurred in 60% of patients. Initiation of CI within 60 minutes of the third dose is occurring in 36.3% of patients. Initial qualitative response from ED staff and nursing has been positive regarding countermeasures and care for the patients.

Conclusions: This project identified the need for improvement efforts in patient care. The goal is to provide more efficient analgesic support; with these adjustments, quicker pain control can be achieved, with this leading to improvement in patient care. It is anticipated that with the eventual achievement of the aims, a decreased admission rate will be noted; for those individuals still requiring further analgesic support, it is felt faster initiation of CI will lead to quicker control of VOE and, subsequently, shorter hospitalizations. Additional countermeasures have been discussed in anticipation to adding to the current interventions to further improve the project's efforts; these ideas are currently being vetted to determine feasibility within our center and their ability to maintain the success of this project over time. Plan will be to continue to run monthly PDSA cycles for 6 months to evaluate response of timing to initial adjustments before integrating further interventions. Qualitative data will be obtained formally during quarterly meetings between hematology and ED representatives.