This article is more than 5 years old. Information may no longer be current.
Hospital protocol improves care for children with sickle cell disease
Click Here to Manage Email Alerts
Vaso-occlusive episode-specific interventions employed by the Boston Medical Center resulted in more than a 50% reduction in ED wait time and an improvement in care for pediatric patients with sickle cell disease, according to results of a quality improvement initiative.
Vaso-occlusive episode (VOE) — one of the most common complications for patients with sickle cell disease — causes extreme and debilitating pain. Previous studies have suggested patients who experienced VOE may wait 65 to 90 minutes in the ED before received their first dose of parenteral analgesia.
Patricia L. Kavanagh
“When a child with sickle cell disease comes to the emergency room with pain from a VOE they likely have been in tremendous pain for hours,” Patricia L. Kavanagh, MD, MSc, a pediatrician at Boston Medical Center and assistant professor of pediatrics at Boston University School of Medicine, said in a press release. “The goal of this initiative was to treat the pain episode as quickly and aggressively as possible so that these children could return to their usual activities, including school and time with family and friends.”
Over 3.5 years, Boston Medical Center adopted changes in ED protocols for how children with sickle cell disease are processed and treated.
The multidisciplinary team used four specific interventions: the development of a standardized, time-specific protocol for patients with VOE; using intranasal fentanyl as the primary pain medication, saving IV administration for the second dosage; using a sickle cell disease pain medication calculator — available online — to quickly determine medication doses based on national data; and improvement of education for patients, their families and providers to ensure high-quality care.
The researchers collected data for three outcome measures: mean time from triage to first parenteral opioid, time to admission/discharge decision and proportion of patients discharged. Researchers took additional measures for process and balance of treatment/care.
Overall, 289 ED visits occurred during the study period.
Using the new interventions, the mean time to first medication reduced 33 minutes, from 56 minutes to 23 minutes.
The mean time from triage to second opiate IV dose also dropped from 106 minutes to 83 minutes. The interventions also led to decreases in mean time for admission decisions (163 minutes to 109 minutes) and discharge decisions (271 minutes to 178 minutes).
There also was a reduction in the average time from triage to the initiation of patient-controlled analgesia (216 minutes to 141 minutes).
With these new interventions, the data indicated that the proportion of patients discharged increased from 32% to 48% (P = .01). Despite that increase, researchers did not observe an increase in the number of patients who returned to the ED within 24 hours, respirator depression or inpatient length of stay.
The researchers acknowledged their results may not be generalizable because it was an initiative at a single institution. Further, the algorithm was not consistently tracked during the initiative, although the data suggested it was routine.
Other limitations included no recording of adverse events, a maximum dose of intranasal fentanyl of 100 µg per dose, and a lack of data on change of pain scores because of documentation errors in the first year of the study.
“By working collaboratively with caregivers across the emergency department to implement these changes, Boston Medical Center has significantly improved the quality of care for [its] young patients with sickle cell disease during emergency situations,” James Moses, MD, MPH, director of patient safety and quality for pediatrics at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine, said in the release.
“While future studies are necessary to determine if these results can be replicated at other hospitals, our data indicates that these initiatives could have tremendous impact on care for kids with sickle cell disease across the country.” – by Anthony SanFilippo
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to Top
Gregory M. Vercellotti, MD, FACP
There is no simple valid and reliable diagnostic test for a sickle vaso-occlusive episodes (VOE). Patients with sickle cell disease go to the ED for evaluation of pain and all too often are not attended to promptly, a delay that accentuates and aggravates a vaso-occlusive crisis through a variety of mechanisms. These include anxiety, sympathetic discharge, sometimes prolonged hypoxia and prolonged dehydration, which can promote a vicious cycle of sickling and vaso-occlusion. EDs are busy and crowded, triaging complex injuries and medical emergencies. Unfortunately, patients with sickle cell disease are sometimes triaged to the back of the line due to the perception that they are drug-seeking rather than experiencing a true VOE, as no definitive diagnostic test can be ordered on the electronic medical record.
The National Heart, Lung, and Blood Institute and the American Pain Society recommend rapid evaluation and treatments of VOE in the ED, with timely pain assessments and repeat analgesia to control pain. Children with sickle cell disease should be given parenteral analgesia within 30 minutes. This recommendation is not consistently followed.
Kavanagh and colleagues conducted a quality improvement initiative to streamline VOE care in an urban pediatric ED. The interventions utilized a standardized time-specific VOE protocol that gave intranasal fentanyl as the first parenteral opiate pain reliever. A personalized sickle cell disease pain calculator allowing patient-controlled analgesia in children aged older than 7 years, as well as education of parents and providers, were implemented. Not surprisingly, this led to shortened time to first and second parenteral opioid doses, more rapid discharge and admission decisions, and a higher discharge rate (48% from the ED).
Standardized algorithms compiled by ED doctors and nurses, social workers, pharmacists, parents and patients should be implemented in every hospital that cares for patients with sickle cell disease with pain crises.As we learn more about the pathophysiology of VOE and pain in sickle cell disease, targeted therapies will be available to minimize hospital admission, pain and organ injury.
Click Here to Manage Email Alerts