SCD: Algorithm Improves Veno-occlusive Episode Care in Kids

Veronica Hackethal, MD

September 23, 2015

A quality improvement intervention for vaso-occlusive episodes (VOEs) has shown that specific interventions can significantly improve emergency department (ED) care for children with sickle cell disease (SCD), and that the gains can be maintained for more than 3 years. The study was published online September 15 in Pediatrics.

"Through the use of a standardized algorithm that included intranasal fentanyl, improving pain medication ordering and verification, and educating providers, patients, and families, we have met and exceeded national recommendations and sustained these gains over time," Patricia Kavanagh, MD, from the Department of Pediatrics, Boston University School of Medicine/Boston Medical Center in Massachusetts, and colleagues write.

VOEs account for most ED visits in children with SCD. Both the National Heart, Lung, and Blood Institute and the American Pain Society recommend quick evaluation and treatment of VOEs, timely pain evaluation, and repeat pain control when necessary. In addition, quality-of-care indicators recommend parenteral analgesia within 30 minutes of ED triage. Studies suggest that many children experience delays of between 65 and 90 minutes, however, before receiving their first dose of pain medications. Inadequate provider knowledge and beliefs about addiction may contribute to delays, the authors explain.

The study was part of a quality improvement initiative at Boston Medical Center that took place from September 2010 until April 2014. The initiative consisted of four interventions implemented over three phases, using the plan-do-study-act cycle of quality improvement. The interventions included intranasal fentanyl as the initial parenteral pain medication, a standardized time-specific VOE protocol (two doses of intranasal fentanyl 5 - 10 minutes apart, then two doses of intravenous opioids every 20 - 30 minutes), an online SCD pain medication calculator providing age- and weight-based dosing specific to children with SCD who may need higher doses, and education for providers, patients, and families.

The analysis included 289 ED visits, with 64% of visits in patients aged 18 years and older (range, 2 - 21 years). Results showed improvements in time to first dose of parenteral opioid (decreased from 56 to 23 minutes), second opiate intravenous dose (decreased from 106 to 83 minutes), admission decisions (decreased from 163 to 109 minutes), discharge decisions (decreased from 271 to 178 minutes), and the start of patient-controlled analgesia (decreased from 216 to 141 minutes).

"Our balancing measures included mean time from triage to the second IV opioid dose to ensure that the use of intranasal fentanyl as the first-line intervention was not delaying subsequent IV dosing," the authors write.

The proportion of patients who received intranasal fentanyl as the first opioid increased from 39% to 75%. The proportion of patients who received the first dose of parenteral opioid within 30 minutes of triage increased from 41% to 75%.

Likewise, the proportion of patients discharged from the ED increased from 32% to 48% (P = .01) without increases in 24-hour readmission, respiratory depression, or inpatient length of stay.

Because the study took place at just one institution, the results may not generalize to other settings. In addition, the study could not assess outcomes such as adverse events or improvement in pain scores as a result of the quality improvement initiative.

The authors note that additional research is needed to evaluate the generalizability of the results, the relative contribution of each intervention to the success of the quality improvement project, other areas that need improvement, and the perspective of providers, families, and patients.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 21, 2015. Abstract

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