Pediatric Emergency Department Adherence to the 2014 National Heart, Lung and Blood Institute Guidelines Targeting Analgesic Therapy in the Management of Vaso-Occlusive Pain Episodes in Children with Sickle Cell Disease: a Multicenter Perspective

Background: Pain is the leading cause of hospitalization and pediatric emergency department (PED) visits for children with sickle cell disease (SCD). The National Heart, Lung and Blood Institute (NHLBI) recommends rapid evaluation and treatment of moderate-severe vaso-occlusive pain episodes (VOEs) in the acute care setting, with timely pain assessments and repeat analgesia delivery to control pain. Quality-of-care indicators for children with SCD include the receipt of parenteral analgesia within 30 minutes of triage or 60 minutes of registration, with frequent pain reassessments and re-dosing of opioids within 30 minutes.

Objective: To assess adherence to the 2014 NHLBI guideline for VOE management with respect to time to 1^st and 2^ndparenteral opioid delivery and time to pain assessment and its reassessment frequency in PEDs across the United States and Canada.

Methods: A retrospective chart review evaluated 20 consecutive charts per site from 20 high-volume PEDs (n=400 charts total) including 14 Pediatric Emergency Care Applied Research Network (PECARN) sites, assessing children age 3-21 years with SCD/VOE receiving parenteral opioids. Time from arrival and triage/room placement (whichever came first) to 1^st and 2^ndparenteral opioid administration, and time to pain assessment and reassessment were assessed. Adoption of bedside registration after triage/room placement at many sites decreased the relevance of a 60-minute window from registration; we therefore focused on triage time/room placement and arrival time to determine our quality outcome measures.

Results: Annual SCD/VOE volume based on ICD-9 code discharge diagnosis for the 20 PED sites combined was 6082 visits, with an admission rate of 66%. Overall admission rate for the 400 patient chart review was 67%. Mean age of the chart review cohort was 14±5 years, 54% were female, and the majority (92%) had HbSS. Median (IQR) time from arrival to room placement was 4 (0, 10) minutes, while median time from triage/rooming to intravenous (IV) catheter placement was 46 (28, 76) minutes. Median time from triage/room placement to 1^st parenteral opioid was 56 (32, 94) minutes; 24% within 30 min, 28% 31-60 min, and 48% >60 min. A total of 46% of patients received parenteral opioids within 60 minutes of ED arrival time. Analysis of children who received two or more opioid doses revealed that only 17% received a 2^nd parenteral opioid dose within 30 minutes of their 1^st dose. Only 17% of the cohort received both their 1^st dose within 30 minutes of triage and 2^nd parenteral opioid within 30 minutes of the first. Mean total number of parenteral opioid doses given while in the PED (min-max) was 2.4 (1-13), over a median (IQR) of 5 hours (4, 7) spent in the PED prior to disposition home or to the inpatient ward. Of admitted patients (n=268), 18% received only a single dose of parenteral opioids while in the PED, 30% received 2 doses and 52% received 3 or more doses. Pain assessment scores were documented in 99% of charts, within a median of 3 minutes (0, 12) of triage/rooming, and 89% had documentation of pain reassessment, occurring within a median of 27 minutes (10.0, 52.0) of 1^stparenteral opioid delivery. The mean number of pain assessments documented during the PED stay was 5±2.

Conclusions:Delays in pain management for children with SCD commonly occur across PEDs, despite NHLBI recommendations for rapid evaluation and treatment of VOEs in the acute care setting. Only a minority of children received rapid parenteral opioid administration defined by the 2014 NIH guidelines, although pain assessment is often performed immediately and with frequent reassessments. Although the majority of patients are rapidly triaged and placed in rooms, children commonly wait 45 minutes or longer for IV placement, which could contribute to delays in delivery of parenteral opioids. This data help identify areas for quality improvement that can be targeted to improve patient care in the future.