P2B012: Reducing Time to Opioid Administration for Vaso-occlusive Crisis in Patients with Sickle Cell Disease

Purpose/Objectives: The National Heart, Lung, and Blood Institute recommends early opioid administration within 1 hour of arrival for treatment of severe pain in sickle cell vaso-occlusive crisis (VOC). Previous studies have shown that intranasal (IN) fentanyl provides effective and timely analgesia in pediatric sickle cell VOC. In 2016, our emergency department (ED) launched a QI initiative where patients noted to have an extremity deformity or burn injuries in moderate to severe pain were offered IN fentanyl to ensure timely opioid administration. This reduced our median time to first opioid to less than 1 hour of arrival for this population. Children with sickle cell disease is a small and underrepresented population in our institution, and there was no such mechanism in place to ensure timely opioid administration.

Design/Methods: A multidisciplinary team including ED and hematology physicians and nurses reviewed baseline data and identified barriers to achieving the national benchmark. Initial considerations were made to utilize metrics for arrival to first opioid, however, given that this project was initiated during an unprecedented volume surge at our institution and at pediatric EDs nationwide, the primary metric utilized was room to first opioid. The primary aim was to decrease time from rooming to first opioid administration in patients in VOC with a pain score of 4 from a baseline of 81 to 45 minutes by June 2023. Secondary aims were to: increase the proportion receiving IN fentanyl from a baseline of 12% to 50% and decrease time to registered nurse (RN) pain reassessment from a baseline of 35 to 20 minutes. We conducted monthly PDSA cycles. Interventions included nursing and physician education, reintroduction of a pre-existing ED Sickle Cell Pain order set, and the addition of best practice alerts (BPA) for nurses and physicians to utilize IN fentanyl. We used statistical process control to examine changes in measures over time.

Results: From June 2021-December 2022, time from rooming to first opioid administration decreased from 81 to 39 minutes (Figure 1). Arrival to first opioid metrics were tracked and did follow a similar decreased from 95 to 57 minutes (Figure 2). Although no centerline shifts have been sustained in the proportion of patients who received IN fentanyl with baseline of 12% (UCL 69, LCL 0), two points of special cause variation were noted. No significant changes have been noted in RN time to pain reassessment which began at a baseline of 35 mins (UCL 95, LCL -25). No cases of adverse reactions were reported.

Conclusion/Discussion: We reduced time to first opioid delivery to treat moderate-severe pain in sickle cell VOC using the implementation of BPAs which promote IN fentanyl utilization. Our current goal is to create a sustainable change in our practice of managing VOC in the ED.