Implementation of a Physician Incentivized QI Strategy to Address Time to Parenteral Analgesia in Patients with Voe in the Pediatric Emergency Department
Authors: Shane Romy , Shah Sanjay J. , Bulloch Blake , Bharath Anita 
Published: November 2021

Abstract
Introduction
Vaso-occlusive episodes (VOE) are the most common cause of pediatric Emergency Department (ED) visits and hospitalizations in Sickle Cell Disease (SCD). The National Heart Lung and Blood Institute published an Expert Panel Report regarding the management of SCD and VOE. Their consensus statement recommends initiating analgesic therapy within 30 minutes of triage or within 60 minutes of registration in the Emergency Department. Previous studies have demonstrated that earlier maximum opioid has been associated with shorter length of hospitalization and improved time to ED disposition decision.
Despite the overwhelming evidence for timely administration of parenteral analgesic, significant delays still exist in delivery of pain medication in the pediatric SCD population. Barriers to timely administration include rapid triage of SCD patients, provider ordering of pain medication, and peripheral intravenous access. Therefore, a standardized approach to pain management may improve ED management of SCD crises.
In order to address timely administration of opiates to SCD patients with VOE episodes in our pediatric ED a SCD pain order set was developed. This order set implemented the use of intranasal (IN) fentanyl as a first line analgesic for SCD patients who presents to the ED with VOE. The purpose of this study was addressing barriers to decrease time to parenteral opioid administration in the pediatric ED.
Methods
This Quality Improvement (QI) measure was performed at a free-standing, urban pediatric ED. Patients were included if they had a diagnosis of SCD and presented with a pain score &gt;5 and without fever.
A PDSA cycle was utilized for designing and evaluating the proposed changes. This cycle consisted of three intervention phases: (1) electronic medical record (EMR) order set development in October 2019, (2) provider incentive for order set use in January 2020, and (3) nursing/patient & family education in April 2020. Baseline data was collected pre-intervention from April-September 2019.
The outcomes measures were mean time to 1 st analgesic, mean time from triage to disposition, Hospital Length of Stay, and overall admission rates. Our balancing measure included 48 hour ED re-visits after discharge.
Results
There were 67 ED visits from April-September 2019 (pre-intervention) and 104 ED visits in the post-intervention data from October-June 2020. There was no significant difference in age or initial pain score in the pre- and post- intervention groups. Improvements were seen in: mean time to first analgesic (58 to 26 minutes), time to disposition (271 to 213 minutes). Hospital length of stay was found to increase with the introduction of IN fentanyl: pre-intervention (120 hours), phase 1 (148 hours), phase 2 (152 hours), phase 3 (218 hours). However, the overall admission rate decreased (55% to 44%). The number of 48-hour ED re-visits remained stable.
Conclusion
By using QI methods to address key barriers in the pediatric ED, we demonstrated that timely administration of parenteral analgesic can be achieved for SCD patients with VOE. Utilizing the EMR order set allowed for more stream-lined care, both by physicians and nursing staff, resulting in more rapid ordering of medication therefore decreasing time to ED disposition. Additional interventions such as provider incentivization to meet the goal of parenteral opioids within 30 minutes of patient arrival led to further improvement. One of the greatest barriers to our QI intervention was hesitancy both by patients and their caregivers regarding the efficacy of IN fentanyl in decreasing pain compared to IV opioid. Further education was needed both for families and medical staff regarding the efficacy of IN fentanyl as a first line analgesic.
It is unclear why overall hospital length of stay was not shown to be decreased with these interventions but this can be offset by an overall decrease in hospital admissions seen with our interventions. This data may be limited by the SARS-CoV-2 pandemic and how psychosocial stressors can impact patients with chronic medical conditions. Length of stay is also confounded by other factors during the hospitalization and acquisition of other diagnoses such as acute chest. Future research is needed to determine if the demonstrated trend of admission rates and hospital length of stay can be replicated in other pediatric EDs and whether earlier opioid administration affects the outcome of VOEs beyond the ED.
Figure 1 Figure 1.

Disclosures
No relevant conflicts of interest to declare.