Assessment of Emergency Department Care for Patients with Acute Pain Crisis after the Formation of a Multidisciplinary Team

Introduction:American Society of Hematology (ASH) guidelines recommend the rapid evaluation and treatment of patients presenting to the Emergency Department (ED) with pain from an acute vaso-occlusive episode (VOE) related to sickle cell disease (SCD). The treatment of severe pain from VOE in SCD is time dependent and time sensitive. Guidelines recommend that treatment for acute VOE with parental opioid analgesia occurs within 60 minutes of ED registration. With respect to the five-level Emergency Severity Index (ESI) triage tool, in which lower numbers indicate higher acuity, patients with SCD are to be assigned an Emergency Severity Index (ESI) of 2 indicating (a) greater disease burden, and (b) the need for high priority bed assignment.

Objectives: We aimed to create a multidisciplinary team of providers to assess and address the existing barriers and facilitators to improving guideline adherence for the management of acute crises in our large academic health system. The primary outcome of this initiative was to improve guideline adherence by ensuring 90% or greater adherence to ESI 2 assignment to acknowledge illness severity as well as timely, within 60-minute opioid analgesia.

Methods: In March 2020, we convened a multidisciplinary team of stakeholders to discuss the ED care of patients with SCD presenting with an acute VOE. The group comprises ED and infusion center nurse champions, nurse educators, nurse leaders, hematologists, palliative care specialists, primary care physicians, psychologists, advanced practice providers and other allied health professionals including social work and spiritual care. Initial monthly meetings established recommendations based on national guidelines and discussed interventions to improve guideline adherence including 1. a nursing driven pain management orderset with subcutaneous and intranasal opioids, 2. a best practice alert with the recommended guidelines. We conducted a retrospective review of ED visit data including all patients with a known diagnosis of sickle cell disease presenting to the ED with a chief complaint of acute pain related to VOE from January 2018-February 2020 and March 2020 to March 2022. We compared the before and after intervention using descriptive statistics.

Results: Of the 760 unique encounters for acute pain related to sickle cell disease from 2018-2022, 406 visits occurred before the group formation and 354 visits occurred after the group formed. Mean age was 30.5 years (+/- 19.5) in the pre-intervention period compared to the 29.5 years (+/- 18.9) in the post intervention period. The time to the first opioid order placed pre-intervention averaged 53.3 mins (+/- 64.9) was not significantly different compared to the post period 75.2 mins (+/- 125.8; p =0.17). The proportion of patients assigned an ESI 2 changed from 49.3% to 50.5%.

Conclusion: While there was a marginal increase in the ESI 2 assignment among SCD patients presenting in acute VOE, there was no significant change in the ED time to first opioid after the formation of a multidisciplinary team.

No relevant conflicts of interest to declare.