526 - Decreasing time to narcotic pain medication in patients presenting with acute sickle cell pain crisis in a pediatric emergency department: a quality improvement initiative
Monday, April 28, 2025
7:00am – 9:15am HST
Publication Number: 526.4080
Allison Adam, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Lina Patel, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Christopher Kaberline, Children's Mercy Hospitals and Clinics, Prairie Village, KS, United States; Ibad Siddiqi, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Leslie Ann. Hueschen, Children's Mercy Hospitals and Clinics, KANSAS CITY, MO, United States
PGY-6 Pediatrician Emergency Medicine Fellow Children's Mercy Hospitals and Clinics Kansas City, Missouri, United States
Background: Guidelines published by the National Heart, Lung and Blood Institute recommend that patients with Sickle Cell Disease who present in acute pain crisis to the emergency department (ED), receive narcotic medication < 60 minutes from arrival. Multi-center studies indicate approximately 50% of institutions are adherent to this level 1a recommendation. From October 2022-October 2023, our institutional median time to narcotic was 61 minutes. Objective: Our aim was to decrease the time to narcotic administration by 10% (61 min to 55 min) in patients with Sickle Cell Disease presenting to the emergency department for acute pain crisis while simultaneously decreasing disparities in our patient population by Oct 2024. Additionally, we sought to increase the percentage of patients within this population to receive their first narcotic in 60 min from 49% to 70%, by Oct 2024. Design/Methods: We utilized PDSA methodology with interventions from October 2023 - July 2024 (Fig 1). The outcome measures included median time to first narcotic, percentage of patients with narcotic administration < 60 minutes, and median time to disposition. Process measures included the percentage of order-set utilization and percentage of patients receiving intranasal Fentanyl. The 24-hour readmission rate was used as a balancing measure. Results: The ED averaged 21 patients presenting for sickle cell pain crisis per month. We met our aim in decreasing time to first narcotic, as well as increasing the percentage of patients receiving their narcotic < 60 minutes, both exhibiting center-line shifts (Fig 2). We saw a decrease in disparity regarding time to first narcotic between patients with low/very low COI (72 min to 51 min) and high/very high COI (58 min to 55 min), a reduction by 29.2% and 4.5% respectively. Intranasal Fentanyl usage increased with 2 centerline shifts, first after clinical pathway/order set revision, and again after adding to weekly metrics for ED staff (Fig 3). We did not observe a statistically significant change in time to disposition, or rate of 24-hour readmission.
Conclusion(s): Developing a standardized process for management of acute pain crises and utilization of Intranasal Fentanyl led to improvement in the time to narcotic, however more significant improvements were evident in the when interventions were directly geared toward front line nursing staff with weekly department huddle metrics.
