Evidence-Based Medicine (EBM) Order Set Improves the Management of Patients with Sickle Cell Disease (SCD) Presenting with Severe Acute Pain Episode to the Emergency Room (ER): A Single Center Experience.

INTRODUCTION: The ER remains main point of entry for most patients with SCD presenting with severe acute pain episode. They are increasingly overburdened, and are not the most appropriate setting in which to manage pain that requires close monitoring, careful opioid dose titration. Institutions have adopted various management strategies to tackle these inadequacies of the ER, such as day hospitals or units. To address this need we developed an EBM order set, to improve management of these patients in such setting.

METHODS: The EBM order set had pain management guidelines as well as interventions considered vital in evaluation of these patients, based on available evidence. Parameters included: Hydration fluid, oxygen use, transfusion, pain adjuncts, vitals signs, blood cultures and chest x-ray when necessary. This is based on the Vanderbilt University Medical Center, Eskind Biomedical Library (EBL), evidence-based care initiatives by providing syntheses of the biomedical literature in response to complex clinical questions, both patient-specific and for protocol/order set development. EBL librarians search the literature, filter the most relevant articles for the question at-hand, and based on an analysis of study methodology; clinical context and represented viewpoints prepare a summary of the overall state of the literature for delivery to the clinical teams. We analyzed the management of patients with SCD who presented with severe acute sickle cell pain episode to the ED for January 2004 – June 2006. Patients were analyzed based on whether they had the evidence based order set utilized in their management or not.

RESULTS: 101 patients with SCD had 1054 ER visits. 420 patient were managed with order sets (39.8%) and 634 patients (60.2%) without. Univariate analysis of components of the order set revealed: Vital signs were measured in 348/420 (82.9%) of patients managed with order set and 327/634 (51.6%)in those without, (P = <0.001%). Pulse oximetry was done in 274/420 (65.2%) was assessed in patients with order set and 22/634 (3.5%) without order set, (P = <0.0001%). Supplemental oxygen was given to 246/420 (58.6%) patients utilizing order set, and 113/634 (17.8%) without order set, (P = <0.0001%). Chest xray was done in 294/420 (70%) patients with order set, while 284/635 (44.8%), (P = <0.0001%). Blood cultures were done in 124/420 (29.5%) of patients utilizing order set, while 150/634 (23.7%) without order set, P = 0.34. D5-1/2NS was hydration fluid of choice in 276/420 (65.7%), while 4/634 (0.6%) in patients without order set, P = <0.0001. 224/420 (63.3%) of patients utilizing order set were admitted, compared to 299/634 (47.2%) without, P = 0.05%. Length of stay (LOS) for patients admitted after initial management with order set was 2.8 days (SD = 3.78), while LOS for patients managed without order set was 2.24 days (SD = 3.294), (P = <0.011).

CONCLUSION: EBM order set utilization resulted in improved evaluation and better monitoring in these cohort of patients, resulting in better care. The paradoxic increased admissions and LOS for patients managed on the order set probably reflects improved diagnosis of complicated SCD pain episode. A multivariate analysis looking at the complex interplay of these variables is ongoing.