463 - Improving Pain Management for Patients with Sickle Cell Disease in The Emergency Department

The 2020 ASH guidelines on management of vaso-occlusive pain crises (VOC) recommend administration of an opioid within 60 minutes of arrival to the emergency department (ED) and the administration of a second opioid within 30-60 minutes of the first if pain persists. Despite these expert guidelines and burgeoning evidence that timely opioid administration improves patient outcomes, poor adherence to these guidelines amongst pediatric emergency departments nationwide persists.

Objective: To increase the percentage of patients presenting to the ED with VOC that received their 2^nd opioid within 45 minutes of their 1^st opioid from 25% to 50% by 1/2021.

Design/Methods:

In 1/2020, we implemented a quality improvement (QI) intervention to improve timely administration of the 2^nd opioid during VOC. Prior to this intervention, ketorolac and three doses of opioids were pre-selected in our “Sickle Cell Disease (SCD) Pain” order set.  The 1^st dose was a standard loading dosing of an intravenous (IV) opioid, and the 2^nd and 3^rd doses were PRN doses, 50% and 25% of the loading dose, respectively. However, there were no instructions regarding the timing of these subsequent opioid doses within the order set. We implemented a text change for the ordering of the 2^nd and 3^rd doses of opioids. Explicit timing administration instructions were added for nurses to administer the opioid if the patient has persistent pain 20 minutes after the prior dose. Provider approval was not needed. Data was analyzed from our QI dashboard for all ED visits with diagnosis codes of SCD in which at least 2 doses of an IV opioid were administered from 1/2018 to 11/2022.

Results:

2,287 visits were included. From 2018-2019, 24.7% (95% CI 22-27.3%) of patients received their 2nd opioid within 45 minutes (min) of their 1^st opioid (mean time from 1^st to 2^nd: 79 min (95% CI 75.5-82.3)).  From 2020-2022, 45.6% (95% CI 42.9-48.4%) received their 2^nd opioid within 45 minutes of the 1^st (mean: 62 min (95% CI 59.2-64.6)). This 21% increase (95% CI 17.1%-24.8%) corresponded to a statistically significant decrease in time between 1^st and 2^nd opioid (p-value:< 0.001). The odds of being discharged were 0.36 times higher in patients who received ketorolac and an IV opioid within 60 minutes of arrival and/or the 2^nd opioid within 45 minutes of the 1^st than the odds of being discharged if the patient did not receive medications within a timely fashion (OR 1.36, 95% CI 1.11-1.67, p-value: 0.0028).

Conclusion(s):

Nursing-driven opioid administration protocols can lead to improved timeliness of second opioid administration for VOC and decreased hospitalization.