Association of Time to Initial Emergency Department Analgesia with Rate of Admission in Patients with Uncomplicated Sickle Cell Disease Vaso-Occlusive Crises

Introduction Painful vaso-occlusive crisis (VOC) is a hallmark of sickle cell disease (SCD). When the pain cannot be managed with home analgesics, patients often present to the Emergency Department (ED) in order to obtain relief. In the ED, the patient may encounter barriers to care that include provider bias, prolonged time to initial analgesic, and inadequate opioid dosing. The goal of this retrospective, single-institution study was to evaluate whether there was an association between the time to initial analgesic and the rate of admission for patients with SCD presenting with VOC. Methods A retrospective, single-institution chart review of adult ED visits between January 29, 2019 and June 30, 2019 was conducted for patients with a history of SCD who presented to the Adult ED for pain related to a VOC. Patients were divided into two cohorts: patients with a calculated door-to-dose time of ≤ 2 hours and patients with a door-to-dose time of > 2 hours. Registration time, time of first opioid administration, and disposition decision were recorded for each visit. The primary outcome of interest was to compare the rate of admission between the two cohorts. Results During the study period, 43 unique patients met the inclusion criteria. These patients were seen for a total of 264 visits for VOC-related acute pain. The overall rate of admission was 49% (130 of 264). The cohort of patients receiving analgesia within 2 hours included 75 (28% of total) subjects, whereas 189 (72%) patients received their first analgesic dose after 2 hours. The admission rate for patients with a door-to-dose time ≤ 2 hours was not significantly different from that for patients with a door-to-dose time > 2 hours (40% vs 53%, P = 0.076) A subgroup analysis was performed on patients presenting to the ED with uncomplicated VOC. This analysis excluded any visits in which patients presented for pain with additional complications (e.g. fever, chest pain, nausea/vomiting, shortness of breath). The purpose of this exclusion was to control for possible confounding by severity or complexity of illness, given that patients who have higher acuity are more likely to be seen faster, but also more likely to be admitted. A total of 47 patient visits from 23 unique patients were excluded from the total visits to perform the subgroup analysis. The most prevalent reasons for exclusion included URI (n=7), nausea and vomiting (n=7), shortness of breath (n=7), and fever (n=7). A subgroup of 37 patients was seen for a total of 217 visits for uncomplicated, VOC-related acute pain. The overall rate of admission was 46% (100 of 217). In 61 (28%) of the encounters analgesia was administered within 2 hours of registration, whereas in 156 (72%) of the encounters the first analgesic was received after 2 hours. In this subgroup of patients presenting with uncomplicated VOC, the admission rate for patients with a door-to-dose time ≤2 hours was significantly lower than that for patients with a door-to-dose time > 2 hours (33% vs 51%, P = 0.016). Conclusion For the entire cohort of patients with sickle cell disease, the administration of analgesia within 2 hours did not result in a statistically significant decrease in rate of admission. In the subgroup analysis, which excludes VOC-related pain visits with complications, the administration of analgesia within 2 hours did result in a statistically significant decrease in the rate of admission. This demonstrates the association between rapid administration of analgesia and a greater likelihood of discharge in the setting of uncomplicated VOC. Based on these preliminary findings, it would be reasonable to allocate additional resources to ensure the rapid administration of analgesia in patients with uncomplicated acute VOC pain crises. Disclosures Dupont: Pfizer: Other: Grant Support. Baer:Al Therapeutics: Research Funding; Incyte: Research Funding; Abbvie: Research Funding; Takeda: Research Funding; Kite: Research Funding; Forma: Research Funding; Astellas: Research Funding. Wilkerson:Pfizer: Other: Grant, Research Funding; Roche: Research Funding; Coaptech: Research Funding; Provay Pharmaceuticals: Research Funding; Cepheid: Other: Research Equipment; Janssen: Research Funding.

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Emergency Department Management of Children with Sickle Cell Disease.

Blood ◽

10.1182/blood.v104.11.1660.1660 ◽

2004 ◽

Vol 104 (11) ◽

pp. 1660-1660

Author(s):

Melissa J. Frei-Jones ◽

Amy L. Baxter ◽

Charles T. Quinn ◽

George R. Buchanan

Keyword(s):

Emergency Department ◽

Steady State ◽

Sickle Cell Disease ◽

Hospital Admission ◽

Sickle Cell ◽

Admission Rate ◽

Categorical Variables ◽

Continuous Variables ◽

Cell Disease ◽

Ed Visits

Abstract Vaso-occlusive crises (VOC) are a common cause of emergency department (ED) visits for children with sickle cell disease (SCD). To better understand our patient population and compare with reports from other centers, we sought to describe the presentation, management, and disposition of children with VOC at our center’s ED. We also aimed to identify predictors of hospital admission. We retrospectively reviewed hospital records of all patients with SCD, age 8–19 years, who presented to our urban pediatric ED in 2003 with a chief complaint of pain. We identified all subjects diagnosed with VOC and not another cause of pain. We obtained the following data for each: SCD genotype; duration of VOC and treatment prior to ED presentation; the nature of analgesia and use of intravenous fluids (IVF) in the ED; hemoglobin (Hgb) concentration; and disposition (admitted, discharged, discharged with subsequent ED visit for same crisis). Categorical variables were evaluated by the χ2 and Fisher exact tests and continuous variables by the t-test. Odds ratios (OR) and 95% confidence intervals (CI) were calculated where appropriate. In 2003, there were 320 ED visits for patients with SCD and pain. Among these, there were 279 diagnoses of VOC in 105 individual patients: 45 had one visit, 25 two visits, and 16 ≥5 visits. Mean number of visits per patient was 2.7; 23 (22%) patients accounted for 145 (55%) visits. Homozygous sickle cell anemia (Hgb SS) was present in 73/105 patients, accounting for 222 (79%) ED visits. Overall admission rate was 179/279 (64%), with 167/179 admitted on their first visit and 12 on their return visit. Subjects with Hgb SS accounted for 147/179 (82%) admissions. Among those discharged who later returned to the ED during the same VOC, the admission rate was 86% (5 returned in 24 hours, 5 in 48 hours, 3 in 72 hours, and one 4 days later). Pre-ED home opioid use was reported in 75% of visits and was associated with increased likelihood of discharge (OR 1.63, CI 0.94–2.84, p=0.082). Duration of VOC before presentation did not significantly affect admission rate and averaged 53.2 hours for admitted patients and 49.7 hours for those discharged (p=0.689). Patients who received IVF in the ED (219/279; 79%) were less likely to be admitted (31% vs 56%, p<0.001). Hgb concentration was increased in 61%, decreased in 36% and unchanged in 3% of patients from steady-state values and was not associated with admission. After receiving 2 doses of morphine, 31 patients were discharged from the ED, while only 5 patients were discharged after receiving 3 or 4 doses of morphine. A departmental VOC protocol was followed for 25.4% of patients, with no impact on admission rate (p=0.290). In this retrospective analysis of a large series of pediatric sickle cell ED visits, patients presented later in their VOC, and admission rate was higher than previously reported. A small proportion of older patients with SCD accounted for most ED visits and hospitalizations. Hgb variation from steady-state was neither clinically significant nor predictive of admission or discharge. In contrast to previous studies, receiving IVF in the ED was associated with a greater likelihood of discharge. Home opioids prior to ED presentation seemed to decrease hospital admission. Adherence to our center’s VOC protocol did not appear to influence disposition from the ED.

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Age-Related Emergency Department Reliance and Healthcare Resource Utilization in Patients with Sickle Cell Disease

Blood ◽

10.1182/blood.v120.21.475.475 ◽

2012 ◽

Vol 120 (21) ◽

pp. 475-475

Author(s):

Morey A. Blinder ◽

Francis Vekeman ◽

Medha Sasane ◽

Alex Trahey ◽

Carole Paley ◽

...

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Healthcare Costs ◽

Research Funding ◽

Transition Period ◽

Cell Disease ◽

Adult Care ◽

Age Related ◽

Ed Visits

Abstract Abstract 475 Introduction: For sickle cell disease (SCD) patients (pts), inadequate care during pediatric to adult transition may result in increased emergency department (ED) utilization. Emergency department reliance (EDR: total ED visits/total ambulatory [outpatient + ED] visits) identifies the proportion of ED visits in relation to all ambulatory visits and differentiates between acute episodic ED users from those who may not have adequate access to outpatient care. The aim of this study is to investigate age-related patterns of EDR and associated healthcare costs in pediatric SCD pts and those transitioning from pediatric to adult care. Methods: State Medicaid data from FL (1998–2009), NJ (1996–2009), MO (1997–2010), IA (1998–2010), and KS (2001–2009) were used for this study. Pts with ≥2 SCD diagnoses (ICD-9 282.6x) and ≥1 blood transfusion were included in the analysis. Pts were followed for as long as they were enrolled in Medicaid. Quarterly rates of outpatient visits, ED visits, EDR, SCD complications associated with ED visits, and ED visits resulting in hospitalization were evaluated. Total healthcare costs were calculated and stratified by outpatient (OP), inpatient (IP), ED, and prescription drug (Rx). SCD complications included pain, stroke, leg ulcers, avascular necrosis, infections, as well as pulmonary, renal, and cardiovascular events. Based on published thresholds, high EDR was defined as >0.33. A logistic regression model was used to assess associations between high EDR and transition age (<18 vs. ≥18 years [yrs]), transfusions, hydroxyurea use, and SCD complications. Other covariates included transfusions during the previous quarter, other relevant medications (e.g.: pain medication, diuretics, anticoagulants), comorbidities (e.g.: hypertension, myocardial infarction, liver disease), and, serving as proxies for overall health status, the frequency of OP, IP, and ED visits during the previous quarter. Regressions analyses were also used to calculate adjusted costs differences between pts with high vs. low EDR. Findings: A total of 3,208 pts were included (FL: 1,550, NJ: 992, MO: 489, KS: 121, IA: 56) in the study. Each pt was observed for an average (SD) of 6.0 (3.1) yrs. Average ED visits/quarter increased from 0.76 to 2.29 between age 15 and 24, reaching a peak of 2.9 at age 36 (Figure 1). Regardless of age, the most common SCD complications associated with ED visits were pain, infection, and pneumonia. Beginning at age 15, EDR rose from 0.17 to reach 0.29 at age 22, and remained high throughout adulthood. The quarterly rate of ED visits resulting in hospitalizations followed a similar pattern. Regression analysis indicated that pts were more likely to have high EDR during the post-transition period (≥18 yrs old, odds ratio [OR]: 2.38, p<0.001) and when experiencing an SCD complication (OR: 4.18, p<0.001). Pts with high EDR incurred statistically significantly higher inpatient and ED costs, resulting in significantly higher total costs (high vs. low EDR, unadjusted costs difference, OP: -$441, p<.001; IP: $7,427, p<.001; ED: $442, p<.001; Rx: -$447, p=0.182; total: $7,376, p<.001 [Table 1]; adjusted costs difference, OP: -$285; IP: $3,485; ED: $120; Rx: -$91; total: $3,086, p<.001 for all). Conclusion: Compared to children, pts transitioning to adulthood relied more on ED for their care. Moreover, pts with high EDR incurred more frequent hospitalizations and significantly higher healthcare costs, highlighting the need to improve transition related support including better access to primary care and increased engagement with SCD patients. Disclosures: Blinder: Novartis Pharmaceuticals: Consultancy, Research Funding. Vekeman:Novartis Pharmaceuticals: Research Funding. Sasane:Novartis Pharmaceuticals: Employment. Trahey:Novartis Pharmaceuticals: Research Funding. Paley:Novartis Pharmaceuticals: Employment. Magestro:Novartis Pharmaceuticals: Employment. Duh:Novartis Pharmaceuticals: Research Funding.

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Episodic Patterns of High Emergency Department Utilization Among Sickle Cell Disease Patients

Blood ◽

10.1182/blood.v128.22.316.316 ◽

2016 ◽

Vol 128 (22) ◽

pp. 316-316

Author(s):

Susan Paulukonis ◽

Lisa Feuchtbaum ◽

Elliott Vichinsky ◽

Mary Hulihan

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Surveillance System ◽

Research Funding ◽

Cell Disease ◽

Ed Visits ◽

High Utilization ◽

The Mean ◽

Over Time

Abstract Background: High utilization of emergency department (ED) services among those with sickle cell disease (SCD) compared to the general population and compared to those with other chronic diseases is well documented in the literature. Some reports note that high utilization is episodic. Most analyses address the problem as a consistent one within patients, rather than consistent over time across the patient population but sporadic for patients. Reducing the high rate of ED utilization among patients with SCD requires an understanding of temporal patterns of ED utilization, the consistency of ED utilization over time by patients and the proportion of the population affected at any given time. Methods: CDC has developed the Sickle Cell Data Collection program (SCDC) to conduct state level surveillance in this disease, and to continue and improve upon work begun through the Registry and Surveillance System in Hemoglobinopathies (RuSH). Through SCDC, California has collected ED and hospitalization data for years 2005-2014 on 4,325 people with SCD. A period of high ED utilization among this cohort was defined as three or more ED encounters (either treat and release or admission to the hospital from the ED) for any diagnosis (not only SCD diagnoses) each fewer than 30 days from the prior visit. The start of an episode of high utilization is the date of the first ED encounter; the end is the date of the last eligible ED encounter. All cohort members were divided into categories of utilization using the proportion of time spent in periods of high utilization divided by the total time in cohort. Total time is cohort is defined as the length of time from the earliest appearance in the ED or hospital data 2005-2014 to the latest appearance. The five categories were defined as no episodes of high ED utilization, and approximate quartile groups for those with high ED utilization: 1.1 to 3.0%, 3.1-10.0%, 10.1% or greater. Age categories (pediatric is < 21 years, and adult is 21 years or older) are defined as patient age at close of study (end of 2014) or at death if prior. Patient ID beginning with P is a pediatric, A is adult in the figures. Results: There were 4,325 individuals with 27,694 person years in the cohort (mean 6.4 person years, median 7.6 person years). Sixty-three percent (n=2,715) of the cohort were aged 21 years and older. Forty-five percent, (n=1,955, 513 pediatric and 1,442 adults) had at least one episode of high utilization during the 10 year study for a total of 7,866 episodes of high utilization. Forty-three percent of patients with one or more high utilization episodes were male, and 63% were between the ages of 20 and 50. Nine percent of these high utilizing patients' total time in the cohort was made up of episodes of high utilization. The mean time span from start of episodes of high utilization to end of the episodes was 63.3 days, median 35 days; mean number of ED visits per episode was 9.0, median 4.0. Most episodes of high utilization were brief: 42.2% included just three visits, and 70.7% included five or fewer ED visits. Among these individuals with episodes of high utilization, the mean number of such episodes was 4.0 over the 10 years study period, and the median was 2.0. Most (76.4%) had five or fewer high utilization episodes, and 35.5% had just one (n = 693). Sample utilization patterns, including hospital admissions, are shown in Figure 1. Conclusions: We demonstrate that among individuals with SCD seen in a population-based, statewide surveillance system, periods of high ED utilization are common, but most SCD patients have only a limited number of short episodes of such utilization. We found that high ED utilization is episodic rather than consistent within individuals, and that while the range of time spent in episodes of high utilization varies, few patients are high utilizers of ED services over a long period of time. Statewide surveillance that follows individual patients over time and in different hospital settings and includes ED utilization (including visits not coded as being related to SCD), provides high quality public health information to inform clinicians and healthcare systems in their development of efforts to reduce ED utilization among those living with SCD. Figure 1 Figure 1. Disclosures Paulukonis: Pfizer: Research Funding; Biogen: Research Funding.

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Episodes of High Emergency Department Utilization Among a Cohort of Persons Living with Sickle Cell Disease

Blood ◽

10.1182/blood-2018-159 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 159-159

Author(s):

Susan T Paulukonis ◽

Eric Roberts ◽

Ron Brathwaite ◽

Ted Wun ◽

Mary M Hulihan

Keyword(s):

Health Care ◽

Emergency Department ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Research Funding ◽

Case Definition ◽

Inpatient Stay ◽

Cell Disease ◽

One Year

Abstract Introduction: Previous research has shown that persons living with sickle cell disease (SCD) are at risk for frequent emergency department (ED) encounters, either with or without an associated inpatient stay. The disease manifests as acute onset vaso-occlusive crises or other severe and unpredictable complications that require immediate care. However, day hospital or other appropriate care settings to manage these health care events are not available to most of the population with SCD. Previous observations suggest that-while ED usage is high overall for this population-this usage is also episodic, with periods of high use interspersed with relatively low usage. We here seek to characterize both high-use and quiescent periods among patients seen in California non-federal hospitals over a 12-year period. Methods: The California Sickle Cell Data Collection project is a statewide effort to use a wide range of administrative, clinical, and other data sources to describe the population living with SCD, their health outcomes, and health care utilization patterns. The data here include 2005-2016 inpatient encounters and ED encounters (with or without an associated inpatient stay) linked by patient identifiers across data set and year. A validated case definition that suggests a high probability of a true SCD 'case' was applied: three or more occurrences of a SCD specific International Classification of Disease Code (version 9 or 10, depending on the year) within any 5 year period between 2005-2016. Only patients who met this case definition and had one year or more of follow-up time in the cohort were included in these analyses. We tabulated the numbers of encounters (inpatient and ED) for each patient for non-overlapping 4-week periods and used Poisson mixture models to evaluate whether encounter frequency could be characterized as a mixture of one or more discrete distributions. Based on these findings, we examined the timing and duration of periods of ED utilization for patients over the course of the study. Quiescent periods are defined as lengths of time in which a person has zero or near zero encounters in ED or inpatient settings. Occasional and high use periods of ED utilization are defined quantitatively by the model (as below). Results: There were 5,090 patients meeting the case definition with one year or more of time in follow up. Patients were followed for a median of 9.8 years (range 1.0 to 11.0). There were 94,196 ED encounters without and 59,064 ED encounters with an associated inpatient stay. A 3-component model best combined predictive power, parsimony, and clinical relevance (Figure 1, upper left), including quiescent periods (mean 0.09 encounters; 88.8% of 4-week periods); occasional-use periods (mean 1.28encounters; 10.8% of 4-week periods); and high-use periods (mean 7.48 encounters; 0.5% of 4-week periods). All but two of the subjects experienced at least one quiescent period during the study, 75.9% experienced at least one occasional-use period, and 8.0% experienced at least one high-use period. Spells of occasional- or high-use lasted a median of 8 weeks regardless of patient age, and 3.6% of these included at least some very high-use. Median lengths of quiescent periods were 24 weeks for patients aged less than 20 years, 16 weeks for those 20 years of age and older. Examples of distribution of utilization over time by certain patients are shown in Figure 1, upper right and both lower panels. Conclusions: The majority of patients with sickle cell disease experience discrete periods during which ED and inpatient hospital encounters are not uncommon, separated by somewhat longer periods with few-to-no encounters. The experiences of -8.0% of patients further include periods during which encounters were very frequent. Patients aged 20 years and older are more likely to experience these high frequency episodes. Further research is planned to identify whether particular health related events or patient characteristics are associated with these high-utilization spells. Figure 1 Figure 1. Disclosures Paulukonis: Bioverativ Inc.: Research Funding; Pfizer Inc.: Research Funding; Global Blood Therapeutics Inc.: Research Funding.

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Optimizing Pain Management for Children with Sickle Cell Disease Vaso-Occlusive Crisis in the Emergency Department

Blood ◽

10.1182/blood-2020-139909 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 44-44

Author(s):

Wilson Andres Vasconez ◽

Claudia Aguilar-Velez ◽

Cristina Matheus ◽

Marie Anne Sosa ◽

Yvonne Diaz ◽

...

Keyword(s):

Emergency Department ◽

Pain Management ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Nursing Staff ◽

Clinical Pathway ◽

Current Evidence ◽

Cell Disease ◽

Discharge Time ◽

Dose Time

Background: Sickle cell disease (SCD) is an inherited blood disorder that predisposes affected children to episodic pain events, known as the Vaso-occlusive crisis (VOC). VOC is the most common reason for emergency department (ED) visits in patients with SCD. This QI project-specific aim was to assess the meantime 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 six months in accordance to best practice standard of care. Methods: Standard quality improvement tools and PDSA methodology was utilized to identify root causes and countermeasures. Root cause analysis included surveys from PED staff, residents, and faculty which demonstrated a lack of practitioner familiarity with current evidence and lack of a standardized pathway. Using this data, countermeasures were implemented, including staff education of guidelines, creation, and deployment of a readily accessible SCD VOC clinical pathway (Figure 1) for PED providers to utilize an updated electronic order set "power-plan" named PED Sickle Cell Crisis Powerplan. A balancing measure while we attempt to reduce the time to first analgesic administration, can be an increase in workload for the nursing staff in the PED. A PED orientation introductory email prompted residents to use our clinical SCD VOC pathway, which was also uploaded in a medical mobile app (The Hub®). We displayed point-of-care reminders, including laminated pathway cards in the PED nursing stations. Key drivers for effective pain management in the ED were identified, including a continuous reassessment of pain as well as an effective standardized pharmacological and non-pharmacological care. Institutional Board Review (IRB) approval was obtained. We recruited nursing champions to help sustain our results. Will measure the average time from triage to IV opioid dosage, to ensure IN fentanyl as drug of choice will not delay subsequent IV opioid dosage administration. PED nursing staff trained to administer IN Fentanyl to patients with a nasal mucosa atomizer, available in the Omnicell. Exclusion criteria of patients with Sickle cell disease with other ICD-10 diagnosis codes, such as acute chest syndrome, or another type of etiology for pain not associated with VOC. The main indicators were assessment-to-dose time; registration-to-discharge time; first dose-to-discharge time and rate of VOC admissions (ED/admissions). All data were collected by discrete time stamps. The database was provided by Jackson Memorial Hospital Informatics and Technology (IT) team. Data were statistically analyzed using Microsoft Office Excel 365/Prism-8. The analysis compared baseline with the first PDSA cycle from December 2019 to February 2020. 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 the lack of a standardized pathway. Nursing surveys reported hesitancy to opioid re-administration from subjective pain assessment and opioid pain management misconception before education. PED staff shift changes, monthly new rotating residents, and the 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 teamwork, 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 PED resulted in check-in to first-dose time reduction by 24.6%. Further steps to sustain our results include guideline reinforcement and interventions with effective pharmacological i.e. intranasal fentanyl and non-pharmacological care. Figure 1 Disclosures No relevant conflicts of interest to declare.

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Emergency Department Follow-up for Adults with Sickle Cell Disease.

Blood ◽

10.1182/blood.v114.22.241.241 ◽

2009 ◽

Vol 114 (22) ◽

pp. 241-241

Author(s):

Paula Tanabe ◽

John W Hafner ◽

Zoran Martinovich ◽

Elena Zvirbulis ◽

Ted Wun ◽

...

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Research Funding ◽

Free Text ◽

Cell Disease ◽

Initial Interview ◽

Pain Scores ◽

Fund Research

Abstract Abstract 241 Study Objectives: To report the patients' ability to make and keep follow-up appointments, obtain analgesic prescriptions, and continued presence of pain for adult emergency department (ED) patients with sickle cell disease, seven and 30 days post ED visit. Barriers to making and keeping appointments and filling analgesic prescriptions were explored. Methods: A multi-center, prospective, longitudinal surveillance study enrolled patients from three academic medical centers (rural and urban). All ED patients ≥18 years with a chief complaint of a sickle cell pain episode were eligible for inclusion. Patients participated in an initial interview within 14 days of their ED visit and/or a second interview 21–37 days from their ED visit. Patients were interviewed at most once per month. The initial interview was conducted either during the hospitalization if admitted, or by follow-up phone call. The 2nd interview was conducted by phone. Pain scores at the time of both interviews were obtained. During the 2nd interview patients were asked if they were able to (1) make and keep a follow-up appointment, (2) whether or not they received and were able to fill an analgesic prescription and (3) associated barriers to either. Each study site conducted a minimum of 10 interviews per quarter. The study period was from October 2007 through July 2009. Descriptive statistics were used to report the data. A paired t-test was used to analyze differences in 7 and 30 day pain scores. Qualitative analysis was used to analyze free text barrier responses to making and keeping an appointment and filling prescriptions. Results: One hundred fifty seven initial interviews and 108 second interviews were completed, 80 different patients, 51% male, mean age 34±10, ages 18–51. Sixty six percent of patients reported they were able to obtain an appointment with a primary care physician after discharge. Of those with difficulty getting an appointment, barriers included: patient did not attempt to obtain an appointment (24%), no current appointments available (21%), difficulty getting a hold of MD office (18%), difficulty finding an MD (15%), no time to go to appointment (9%), lost MD phone number (6%), unspecified (6%), and no money for appointment (3%). Sixty six percent of patients with an appointment reported keeping their appointment or had a future appointment scheduled. Reasons why patients did not keep their appointment included: had to work, out of town, in hospital before appointment, forgot when appointment was, no money for appointment. At discharge from the ED or hospital, 70% of patients reported they needed an analgesic prescription and 66% of patients received a prescription for analgesics. Nineteen percent of patients reported difficulty filling their prescription. Difficulties included: prescription written incorrectly, dose was not available at pharmacy, pharmacy was closed, no money for prescription, homeless. Initial interview pain scores (median, IQR) were 7; (6.25, 8), and 2nd interview pain scores were 8; (7, 9). 57 patients participated in both an initial and follow-up interview and no differences in pain scores were reported, (p=0.83). Forty three percent of patients (who were discharged home from the ED) during the initial interview, and 59% of patients during the 2nd interview reported being unable to manage their pain at home. On the second interview, 74% of patients reported they were currently experiencing sickle cell pain and 72% reported they were taking pain medication every day. Conclusion Many ED patients did not keep follow-up appointments and a smaller number of patients experienced barriers to filling analgesic prescriptions. Over half of patients reported continued pain in the severe range 30 days after the ED visit. Disclosures: Tanabe: NIH, and Mayday Fund: Research Funding. Hafner:Mayday Fund: Research Funding. Martinovich:Mayday Fund: Research Funding. Zvirbulis:Mayday Fund: Research Funding. Artz:Mayday Fund: Research Funding.

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Impact of Intravenous Opioid Shortage on Managing Pain Crisis in Sickle Cell Disease

Blood ◽

10.1182/blood-2019-122249 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3390-3390

Author(s):

Jin Han ◽

Santosh L. Saraf ◽

Michel Gowhari ◽

Faiz Ahmed Hussain ◽

Shivi Jain ◽

...

Keyword(s):

Sickle Cell Disease ◽

Sickle Cell ◽

Research Funding ◽

Admission Rate ◽

Trend Test ◽

Inpatient Service ◽

Cell Disease ◽

Opioid Dose ◽

Management Protocol ◽

Number Of Visits

Background: Vaso-occlusive crisis (VOC) is the hallmark complication of sickle cell disease (SCD) (1), and usually requires intravenous (IV) opioid treatment in emergency room (ER) or acute care center (ACC), a designated observation unit to manage uncomplicated VOC (2). Starting October 2017, there was a critical nationwide drug shortage in parental hydromorphone, a commonly used medication to treat VOC. In April 2018 the University of Illinois Health System (UI Health) adopted a standardized pain management protocol that limited opioids in the ER or ACC to two doses of IV or IM morphine and/or oral opioid. This study evaluates the impact of this standardized pain management protocol on managing VOC in SCD. Methods: A total of 373 SCD adults treated at UI Health from May 2017 to Oct 2018 had at least one ER or ACC visit or hospitalization for VOC. Data on VOC-related patient visits to the ACC, ER, and admissions to the inpatient floors were collected from the electronic medical record and evaluated based on three time periods (prior to shortage: May 2017-Oct 2017; transition: Oct 2017-Apr 2018; and post protocol: Apr 2018-Oct 2018). Descriptive statistics, the Cochrane trend test and Jonckheere-Terpstra trend test were used for data analysis. The study was approved by the Institutional Review Board prior to the initiation of chart review. Results: Between May 2017 and Oct 2018, the 373 SCD adult patients had a total of 1,915 ACC, 2,635 ER and 1,832 inpatient visits. After implementation in April 2018, the compliance rate with the standardized pain protocol was 99.7% in the ACC and 85.1% in the ER. In the ACC, the number of visits decreased after standardized pain protocol implementation, whereas the number of visits increased in the ER (Figure 1). The admission rate to the inpatient service from the ACC increased significantly while the admission rate from the ER remained relatively stable (Table 1). The numbers of opioid doses and the total opioid dose to treat VOC decreased in the ACC, but not in ER. Utilization of oral opioids increased in both settings (Table 1). The number of inpatient hospitalizations increased with implementation of the standardized protocol (542 vs. 626 vs. 664), and the 30-day readmission rate increased (49% vs. 51% vs. 57%, p = 0.003), but the length of hospital stay was reduced (p < 0.001). Summary: Implementation of a standardized pain treatment protocol due to the parenteral hydromorphone shortage decreased the utilization of the ACC compared to the ER and the inpatient service, and resulted in reduced opioid dose but increased admission rates from the ACC. The 30-day readmission rate to inpatient service increased but the length of stay was reduced. A standardized pain protocol that limits opioids to two doses in the acute setting may not be an optimal approach. Reference: F. B. Piel, M. H. Steinberg, D. C. Rees, Sickle Cell Disease. N Engl J Med376, 1561-1573 (2017).J. Han et al., Program expansion of a day hospital dedicated to manage sickle cell pain. Am J Hematol93, E20-E21 (2018). Disclosures Saraf: Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding. Gordeuk:CSL Behring: Consultancy, Honoraria, Research Funding; Global Blood Therapeutics: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Modus Therapeutics: Consultancy, Honoraria; Imara: Research Funding; Ironwood: Research Funding; Inctye: Research Funding; Pfizer: Research Funding; Emmaus: Consultancy, Honoraria.

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A Resident-Led Quality Improvement Initiative to Optimize Care for Children and Young Adults with Sickle Cell Disease Vaso-Occlusive Pain with Intranasal Fentanyl in the Emergency Department

Blood ◽

10.1182/blood-2021-152849 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 1892-1892

Author(s):

Wilson Andres Vasconez Samaniego ◽

Cristina Matheus ◽

Claudia Aguilar-Velez ◽

Prasanth Narahari ◽

Priyanka Nair ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Pain Management ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Clinical Pathway ◽

Cell Disease ◽

First Line ◽

Discharge Time ◽

Dose Time

Abstract Background: Sickle cell disease (SCD) is an inherited blood condition that predisposes affected patients to severe vaso-occlusive (VOC) pain events. The NHLBI (last revised in 2014) and ASH guidelines (last revised 2020) recommend a door-to-first dose should be within 60 minutes vs. 30 minutes from registration, and reassessment and re-administration of medications should be every 30 minutes. Non-IV routes of administration, i.e. intranasal (IN) can facilitate rapid analgesic treatment. Recent studies have shown IN Fentanyl as an effective pharmacological strategy to treat vaso-occlusive pain episodes. Methods: This resident-led Quality Improvement specific aim was to reduce the meantime from check-in to first analgesic delivery to SCD patients with VOC presenting to the Pediatric Emergency Department (PED) by at least 20% during 12 months and to improve the overall care of SCD VOC in accordance to best practices. PDSA cycle methodology was utilized to identify root causes, countermeasures, and key drivers (Figure 1A). We implemented a SCD VOC clinical pathway for PED providers to utilize our enhanced and updated version of an electronic order set named "PED Sickle Cell Crisis Power Plan" that includes IN Fentanyl as first-line therapy for SCD VOC. IRB approval was obtained. PED nursing staff was trained to administer IN Fentanyl with a nasal mucosa atomizer. Exclusion criteria of patients with SCD with other ICD-10 diagnosis codes, i.e pain not associated with VOC. The main indicators were assessment-to-dose time; registration-to-discharge time; first dose-to-discharge time, and rate of VOC admissions. Data was collected by discrete-time stamps and statistically analyzed using Excel 365. The analysis compared baseline with initial PDSA cycles from December 2019 to February 2020, and from September 2020 to March 2021. Results: From September 2020 to February 2021, a total of 54 encounters for SCD VOC qualified clinically to receive IN Fentanyl. A total of 49 of these encounters received this medication, while 5 refused its administration. Patient demographics: Male-to-female ratio was 53% and 47%, respectively. The majority of the patients seen were adolescents (63% with ages between 12-21 years). African-American participants represented 88% and non-Hispanics 84%. After our interventions, 94% of encounters have documented pain reassessment in their electronic medical records. IN Fentanyl was first introduced in the PED in September 2020, and became the first medication to be administered in 94% of the encounters. The average length of stay in the PED was 269 minutes (4 hrs. with 29 minutes). The SCD VOC Clinical Pathway was used in 90% of the encounters and the SCD VOC Power Plan was used in 80% of them. From the total of encounters, 59% required admission to the floor for further pain management strategies. As shown in the control chart (Figure 1.B), the meantime from check-in to first analgesic delivery to patients with VOC presenting to the PED was reduced to under 40 minutes by February 2021. After the implementation of IN Fentanyl, there is an overall improvement of the waiting time for administration of medications of more than 70 minutes (from 138 min down to 67 minutes). Most importantly, 37% (18/49) of SCD VOC events were discharged after successful VOC pain management in the PED. Discussion: PED staff surveys demonstrated a lack of familiarity with current VOC guidelines and a standardized pathway. Medication refusal of IN Fentanyl was found to be related mostly to patient preference, poor knowledge about side effects, and parental fear for oversedation before our interventions. Conclusion: A multi-disciplinary team was formed to assist health care providers in the ED to deliver optimal care to patients with SCD based on the current evidence-based SCD VOC clinical pathway and efficient pharmacological intervention with IN Fentanyl. Standardized procedures to treat and reassess pain for SCD VOC patients in the PED resulted in check-in to first-dose time reduction by 47%. There was a consistent improvement in Length of Stay in the PED, which decreased more than 60 minutes (from 5 hrs. 21 min. to 4 hrs. 29 min). There is a significant improvement of quality in the care of VOC including 1. Pain scoring system. 2. Documented pain reassessment. 3. Use of a multidisciplinary reviewed protocol that includes PED SCD VOC clinical pathway, and an updated order set power plan with IN Fentanyl as the first line. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

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