Decreasing Time to Narcotic Pain Medication in Patients With Sickle Cell Disease Presenting With Acute Pain Crises in a Pediatric Emergency Department: a Quality Improvement Initiative.
Year: 2025
Type: preprint
Study design: Clinical Trial
Abstract: Objectives Acute Pain Crises (APC) are the most common reason for a patient with Sickle Cell Disease (SCD) to seek care in an Emergency Department (ED), and most institutions are not adhering to the national recommendations of narcotic administration in < 60 min. This initiative aimed to decrease the time to narcotic administration in patients with SCD presenting to the ED for APC by 10% (from 61 to 55 min) by October of 2024, while decreasing patient disparities as it relates to the Childhood Opportunity Index (COI). Methods A quality improvement initiative was performed from October 2023 to October 2024 focusing on improvement in timely narcotic administration in an urban quaternary pediatric ED. 5 interventions were performed and included (1) development of a multi-disciplinary team, (2) publication of a clinical pathway with the routine use if Intranasal Fentanyl (INF), (3) provider, (4) nursing and (5) patient/family education. Outcome measures included the median time to first narcotic, the percentage of patients with narcotic administration less than 60 minutes, and the median time to disposition (admit or discharge). Process measures included the percentage of order set utilization and percentage of patients who received intranasal Fentanyl (INF). 24-hour readmission rate was utilized as the balancing measure. Results During the study there was an average of 21 patients with SCD presenting for APC per month. Time to first narcotic improved from 61 to 42 minutes and the percentage of patients receiving their first narcotic within 60 minutes improved from 54% to 73.8%. Intranasal fentanyl use increased from 1.1% to 70.2%, warranting 2 centerline shifts. There was not a statistically significant impact on order set usage, the median time to patient disposition, or a change in the rate of 24-hour readmissions. The time to first narcotic was improved for all levels of patient Childhood Opportunity Index (COI) and there was a decrease in disparities between the low/very low and high/very high COI. Conclusion Standardized management guidelines with the use of INF led to improvement in time to first narcotic in patients with SCD presenting to the ED for management of APC. The most dramatic increase in INF use occurred following interventions focusing on nursing education with recurring department huddle board discussions, which highlights the importance of the nursing role amidst the entire care team in the management of APC in patients with SCD. Further investigation is needed to understand the drivers of patient preference to accept or refuse INF for pain control and what patients may value the benefits of immediate administration via the intranasal route.
Authors: Allison Adam, Chris Kaberline, Lina Patel, Ibad Siddiqi, Leslie Hueschen
Institution: Children's Mercy Hospital
Language: English
Subfield: Genetics
Field: Medicine
Domain: Health Sciences
Open Access status: gold
OpenAlex ID: W4413812672