Improving the Care of Adults with Sickle Cell Disease in a Large Tertiary Hospital Emergency Department By Incorporating Patients' and Providers' Feedback
Authors: He Chong Bin , Pham Dan , Kronenfeld Rachel S. , Lewis Azaria , Harrington Thomas , Lee Lilly , Chavez Hector , Rogers Brent , Brauer Emily , Bloomberg Maya , Alvarez Ofelia A. 
Published: December 2024

Background. Jackson Memorial Hospital (JMH), a large tertiary hospital in Miami, Florida, receives over 12,000 emergency visits annually. Sickle cell vaso-occlusive pain episodes (VOC) are the most frequent reason for adults with sickle cell disease (SCD) to visit the emergency department (ED). The American Society of Hematology (ASH) and the National Heart, Lung, and Blood Institute (NHLBI) recommend prompt opioid administration within 60 minutes of ED arrival for these patients. VOCs should be assigned an Emergency Severity Index (ESI) level 2 priority.

Objective of the quality improvement (QI) initiative. To assess and improve VOC management at JMH Adult ED by incorporating patient and provider feedback as part of a QI initiative sponsored by HRSA (6 U1EMC42461).

Methods. Between January and October 2023, all emergency department (ED) encounters for ten high-utilizer patients (mean age 36 years; 6 males, 4 females; 8 HbSS, 2 HbSC) were examined through a review of their electronic medical records. Patient flow times, measured in minutes, were analyzed from registration to discharge or hospitalization. Patients were surveyed using written Likert scale questionnaires to assess ED performance, including ratings of likes, challenges, and overall satisfaction with the encounters (very satisfied, somewhat satisfied, neither satisfied nor unsatisfied, somewhat unsatisfied, or very unsatisfied). Additionally, seven ED staff members, including medical providers and nurses, were interviewed for ideas to improve care for VOC patients.

Results. There were 63 ED encounters, with 90.8% requiring hospitalization. Despite patients being assigned ESI level 2, the average wait time from registration to first opioid administration was 173 minutes. The average times for rooming, IV/port access, opioid order, and opioid administration were 68, 31, 33, and 41 minutes, respectively. Only 19.1% of the ED encounters adhered to the recommended 60-minute timeframe. Patients expressed being “somewhat satisfied” and voiced concerns about long wait times, difficulties in obtaining IV/port access, and perceived poor communication and empathy from staff.

Interviews with ED staff highlighted several areas for improvement, including addressing high patient volume, providing general staff education, offering nurse training on port access and the use of ultrasound machines for difficult IV access, and encouraging providers to ask patients about their preferred opioids. Staff expressed a strong commitment to making significant changes to improve care. Ongoing discussions with ED leadership are taking place to enhance ED flow and reduce opioid administration times.

Conclusions. JMH is a large tertiary hospital with over 12,000 ED encounters annually. Despite appropriate ESI assignments, only 19.1% of ED visits for VOC among ten high utilizers met the recommended standard for opioid administration, leading to patient dissatisfaction. Our goal is to increase the percentage of all patients who receive opioids within 60 minutes from 19.1% to at least 50% by December 2025.

Priority change ideas include ongoing nurse training in port access and the use of vein-finding ultrasounds, staff education on VOC management, subcutaneous opioid administration or intranasal fentanyl to reduce opioid wait times, and the integration of individualized pain plans into medical records. Data are being collected with the help of information technology to assess trends.

We strongly recommend the assessment of opioid wait times as an essential ED QI measure. Both patients' and providers' opinions should be considered when developing plan-do-study-act cycles (PDSA) and change ideas.