Multi-Modal Intervention for Inpatient Management of Sickle Cell Pain Significantly decreases the rate of Acute Chest Syndrome.

Painful vaso-occlusive episodes (VOE) account for the majority of hospitalizations and nearly all morbidity in children with sickle cell disease (SCD). Frequently, VOE progresses into acute chest syndrome (ACS), a leading cause of mortality in SCD. Few strategies exist to prevent this potentially fatal complication. We present the results of a multi-modal intervention to improve the inpatient management of SCD. We performed a before-and-after prospective multi-modal intervention. All children with SCD admitted for uncomplicated VOE during the two-year study period were eligible. The multi-modal intervention included standardized VOE admission orders, monthly house staff education, and one-on-one patient and caregiver education. ACS was defined as a new radiologic density on chest radiograph. A total of 332 admissions for uncomplicated VOE occurred during the study period; 159 before the intervention and 173 during the intervention. The ACS rate declined by 50% during the intervention period (25%, 39/159 to 12%, 21/173; p=0.003). No significant difference was found in patient demographics, amount of intravenous fluid administered, frequency of normal saline bolus administration, or cumulative opioid amount delivered in first 24-hours. Patient controlled analgesia (PCA) use was more common after the intervention (52%, 82/159 vs 73%, 126/173; p=0.0001) and fewer patients required changes in analgesic dosing within the first 24-hours after admission (26%, 42/159 vs 16%, 28/173; p=0.015). PCA-use protected against progression to ACS (OR 0.5; 95% CI 0.3–0.0.94) while patients needing escalation of pain medications in the first 24-hours were more likely to develop ACS (OR 2.5; 95% CI 1.3–4.6). A multi-modal intervention to change physician behavior successfully improved patient outcomes by reducing the ACS rate.