P0293 - Optimizing Pain Management For Children With Sickle Cell Disease Vaso-occlusive Crisis In The Pediatric Emergency Department

Background:
Sickle cell disease (SCD) is an inherited blood disorder which predisposes affected children to episodic pain events, known as Vaso-occlusive crisis (VOC). VOC is the most common reason for emergency department (ED) visits in patients with SCD. National guidelines recommend analgesic therapy within 60 minutes of registration.

This QI project specific aim was to assess the mean time from check-in to first analgesic delivery to patients with VOC presenting at Holtz Children’s Hospital Pediatric Emergency Department (PED) and to reduce this time by at least 20% (from 90 minutes to 72 minutes) during a six-month period in accordance to best practice standard of care.

Methods:
The project included patients, ages 0–21, admitted to Holtz Children’s Hospital PED with SCD VOC pain from December 2018 to March 2020. Baseline data includes patients from December 2018 to November 2019. Exclusion criteria consisted of SCD patients with diagnosis not associated with VOC. Main indicator measured included “check-in to first dose” in minutes. Demographic variables included age, gender and ethnicity. Standard quality improvement tools and PDSA methodology were utilized.

PDSA cycle 1 consisted of: [1] creating a sickle cell disease VOC clinical pathway (Figure 1) presented to PED house staff and provided in a mobile app (The Hub®) [2] displaying laminated cards in the ED working stations. PDSA cycle 2 reinforced standardized guidelines education to residents and nursing staff.

Results: From December 2019 to February 2020, a total of 65 VOC encounters were analyzed. Baseline data average check-in to first dose time was 90.3 minutes, following intervention average time lowered to 70.3 minutes, which corresponds to a 24.6% decrease (Figure 2).
Patients ages 15–19 represented the majority of the participants (37.9%). Male-to-female ratio was 51.5% and 48.5%, respectively.
Afro-American non-Hispanic participants represented 91.2% of the study and Hispanic 8.8%.

Discussion:
PED staff surveys demonstrated a lack of familiarity with current VOC guidelines and lack of a standardized pathway. Nursing surveys reported hesitancy to opioid re-administration from subjective pain assessment and opioid pain management misconception prior to education. PED staff shift changes, monthly new rotating residents and unpredictable nature of PED workflow are factors that can affect consistent VOC management. Implementing a clinical pathway available to the staff and integrating it into the workflow reduces the variability in the management of VOC visits. Hence, through team work, continuous pathway reinforcement and education our outcome was associated with improvement in average time from check-in to first-dose.

Conclusion:
Standardized procedures to treat and reassess pain for sickle cell disease VOC patients in the Pediatric Emergency Department resulted in a check-in to first-dose time reduction by 24.6%. Further steps to sustain our results include guideline reinforcement, nursing champions recruitment and interventions with effective pharmacological and non-pharmacological care.