A Quality Improvement Initiative to Improve Inpatient Pain Management for Pediatric Patients with Sickle Cell Disease

Purpose/Objectives: Vaso-occlusive crisis (VOC) is the leading cause of hospitalizations and emergency department visits among patients with Sickle Cell Disease (SCD). Early and aggressive pain management is the cornerstone of VOC management in the emergency room and has been linked to decreased admission rates. However, once patients are admitted, VOCs are often undertreated, leading to poor quality of life and excessive health care utilization.

Aim Statement: By June 30,2021, we aim to increase basal acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) to ≥90% of patients with SCD admitted for VOC who otherwise do not have contraindications, and basal opioids to ≥90% of patients who have a home prescription for opioids and otherwise do not have contraindications. Our secondary aims include evaluating as needed (PRN) opiate use and length of hospitalization.

Design/Methods: A prospective single-center quality improvement project was conducted to evaluate and improve timely and appropriate pain management for pediatric patients with SCD in a 26-bed pediatric ward within a public teaching hospital. Interventions targeted towards residents were implemented using Plan-Do-Study-Act cycles beginning in September 2020. These included inpatient pain management didactics and handouts, VOC inpatient pain control order sets, and individualized home pain plans. Pre- and post-intervention data were collected from the electronic medical record from January 2017 to June 2021.

Results: Prior to interventions, 15 patients accounted for 88 hospitalizations with a median length of stay of 4 days. Basal acetaminophen and NSAIDs were scheduled for 18% and 95% of hospitalizations, respectively. Patients received a median of 0 MME of basal opioid and 29.5 MME of PRN opioid within 24 hours of admission. Post-intervention, 8 patients accounted for 17 hospitalizations with a median length of stay of 4 days. Acetaminophen and NSAIDs were both ordered for 100% of hospitalizations. Patients received a median of 2.5 MME of basal opioid and 37.5 MME of PRN opioid within 24 hours of admission. A basal opioid regimen was started in 30% of hospitalizations prior to intervention and 53% of hospitalizations post-intervention.

Conclusion/Discussion: QI efforts targeted at physician education and establishing hospital standards for pain management can improve pain control in pediatric patients with SCD. However, data that these interventions ultimately affect outcome measures such as length of stay is lacking. This may be in part due to the low number of patients and presence of patients who disproportionately utilize resources. In our data set, post-intervention length of stay was inflated by two complex patients who accounted for 74 of 105 hospitalization days. For these patients, additional interventions such as mental health support, non-pharmacologic therapy, and case management may be beneficial. Continued research and follow-up are needed to improve VOC treatment and understand the impact of these interventions on hospitalizations and quality of life.