Improvement In Acute Management of Vaso-Occlusive Pain In Pediatric Sickle Cell Disease with Use of a Clinical Pathway

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 2660-2660
Author(s):  
Katherine Ender ◽  
Jennifer Freed ◽  
John Babineau ◽  
Mary Tresgallo ◽  
William Schechter ◽  
...  
Keyword(s):  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Clinical Pathway ◽  
Clinical Pathways ◽  
Capture Rate ◽  
Tertiary Care ◽  
P Value ◽  
Time Interval ◽  
Cell Disease

Abstract Abstract 2660 Background: Sickle cell disease causes considerable morbidity and mortality. Three guidelines exist for the management of vaso-occlusive pain, although studies have shown that these guidelines are not well followed and that there is considerable variation in care. Investigations of clinical pathways for pediatric sickle cell pain have not been published to our knowledge, but research in other pediatric conditions has shown that the implementation of clinical pathways can improve medical care. We initiated an investigation of the effects of a pain management pathway for sickle cell vaso-occlusive crisis in the emergency department (ED) with the hypothesis that the introduction of a clinical pathway would improve the efficiency and efficacy of acute pain management. Methods: We conducted a prospective, cohort study from February 2009 to March 2010 in an urban, tertiary care ED. We collected data from patients aged 3–18 years old with sickle cell disease who presented to the ED with vaso-occlusive crisis (VOC) pain. Baseline data was collected for five months prior to the introduction of the clinical pathway, followed by a four-week time interval in which the ED physicians and nurses were in-serviced on the pathway, followed by six months in which data was collected with the clinical pathway in place. Our pathway, which is in checklist format with instructions for triage, monitoring, medication administration, and timing of assessments and interventions, was developed by representatives from the divisions of Pediatric Hematology, Pediatric Emergency Medicine, and Pediatric Pain Medicine, Symptom Management and Palliative Care and based upon current standard-of-care guidelines. Results: Over the eleven month study period, 68 patients were enrolled. Random chart audits revealed a 75% capture rate. Significant improvement was demonstrated in time interval to first analgesic from 74 minutes to 42 minutes (p value 0.02), time interval to first opioid from 94 minutes to 46 minutes (p value < 0.01), and time interval to subsequent assessment of pain score from 110 minutes to 72 minutes (p value 0.02). The percentage of patients who received ketorolac also increased from 57% to 82% (p value 0.03). Change in pain scores was not significantly different, nor was admission rate. Conclusions: Implementation of a pain management pathway for sickle cell VOC led to an improvement in the time interval to administration of first analgesic and time interval to pain re-assessment, bringing these aspects of patient management closer to accepted guidelines. Whether improvement can be made in admission rates, change in pain ratings, and patient satisfaction will require further study. Disclosures: No relevant conflicts of interest to declare.

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

Blood ◽  
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.

scholarly journals 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 ◽  
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.

#611 Utilization of a clinical pathway to facilitate management of sickle cell disease-related vasoocclusive events in children

1998 ◽  
Vol 20 (4) ◽  
pp. 376
Author(s):  
W. C. Owen ◽  
J. P. Pestian ◽  
S. Hughes ◽  
A. D. Wenger ◽  
E. Vasser ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Clinical Pathway ◽  
Cell Disease

Parent Perspectives on Pain Management, Coping, and Family Functioning in Pediatric Sickle Cell Disease

2007 ◽  
Vol 46 (4) ◽  
pp. 311-319 ◽  
Author(s):  
Monica J. Mitchell ◽  
Kathleen Lemanek ◽  
Tonya M. Palermo ◽  
Lori E. Crosby ◽  
Alisha Nichols ◽  
...  
Keyword(s):  
Pain Management ◽  
Sickle Cell Disease ◽  
Family Functioning ◽  
Sickle Cell ◽  
Parent Perspectives ◽  
Cell Disease ◽  
Pediatric Sickle Cell Disease

Experience of an Interdisciplinary Pediatric Pain Service

PEDIATRICS ◽  
1991 ◽  
Vol 88 (6) ◽  
pp. 1226-1232
Author(s):  
Barbara S. Shapiro ◽  
David E. Cohen ◽  
Kenneth W. Covelman ◽  
Carol J. Howe ◽  
Sam M. Scott
Keyword(s):  
Sickle Cell Disease ◽  
Patient Care ◽  
Sickle Cell ◽  
Health Care Professionals ◽  
Tertiary Care ◽  
Direct Patient Care ◽  
Team Approach ◽  
Cell Disease ◽  
Number Of Patients ◽  
Physician Time

This article is a report of our experience with an interdisciplinary pain service in a large tertiary care pediatric hospital. During the first 2 years of operation, we received 869 consultations and referrals from more than 19 hospital divisions. Postoperative pain was the most frequent reason for consultation (56% of patients). Patients with pain related to cancer and sickle cell disease comprised 25% of the consultations. The remaining patients had a wide variety of primary diagnoses and causes of pain. We calculated the time spent by pain service physicians in direct patient care. The majority (63%) of physician time was spent with a small number of patients (17%). Most of these patients had pain that was unrelated to surgery, cancer, or sickle cell disease, and many posed dilemmas in diagnosis and treatment. Physician time was correlated directly to the use of psychologic and physical therapies for the pain, involving multiple team members. This experience supports the demand for an interdisciplinary pain service in a tertiary care children's hospital. A significant amount of physician time is necessary to provide patient care and to maintain a team approach, however, and pediatricians and other health care professionals who aim to implement such services should be cognizant of the time required.

scholarly journals Sickle cell disease pain management and the medical home

Hematology ◽  
2013 ◽  
Vol 2013 (1) ◽  
pp. 433-438 ◽  
Author(s):  
Jean L. Raphael ◽  
Suzette O. Oyeku
Keyword(s):  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Medical Home ◽  
Cost Effective ◽  
Cell Disease ◽  
Patient Centered ◽  
Centered Care ◽  
The Individual ◽  
Effective Models

Pain is the most common cause for hospitalization and acute morbidity in sickle cell disease (SCD). The consequences of SCD-related pain are substantial, affecting both the individual and the health care system. The emergence of the patient-centered medical home (PCMH) provides new opportunities to align efforts to improve SCD management with innovative and potentially cost-effective models of patient-centered care. The Department of Health and Human Services has designated SCD as a priority area with emphasis on creating PCMHs for affected patients. The question for patients, clinicians, scientists, and policy-makers is how the PCMH can be designed to address pain, the hallmark feature of SCD. This article provides a framework of pain management within the PCMH model. We present an overview of pain and pain management in SCD, gaps in pain management, and current care models used by patients and discuss core PCMH concepts and multidisciplinary team–based PCMH care strategies for SCD pain management.

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

2021 ◽  
Author(s):  
Wilson Andres Vasconez ◽  
Claudia Aguilar-Velez ◽  
Cristina Matheus ◽  
Hector Chavez ◽  
Roxana Middleton-Garcia ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Pediatric Emergency ◽  
Pediatric Emergency Department ◽  
Cell Disease

scholarly journals Vaso-occlusive crisis in sickle cell disease: current paradigm on pain management

2018 ◽  
Vol Volume 11 ◽  
pp. 3141-3150 ◽  
Author(s):  
Samuel N. Uwaezuoke ◽  
Adaeze C. Ayuk ◽  
Ikenna K. Ndu ◽  
Chizoma Eneh ◽  
Ngozi R Mbanefo ◽  
...  
Keyword(s):  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Cell Disease ◽  
Current Paradigm
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