Pain Medication: Time to First Dose in Sickle Cell Acute Care in Two Settings of a Large Urban Hospital
Authors: Johnson Bonnye , Lei Dawn , Furtado Nicholas F , Hashmi Saman K. , Molokie Robert , DeSimone Joseph , Hassan Johara , Gowhari Michel , Gordon Tara , Dowell Darcel , Pendarvis Glenda , Prendergast Heather , Gordeuk Victor R. , Hsu Lewis L. 
Published: October 2019

Abstract
Abstract 4693
Time to first dose (TTFD) of pain medication is one of the important measures of quality care in sickle cell disease (SCD), according to a new expert consensus (Wang et al., 2011). It is well documented that treatment of pain crises in an acute care center with immediate and aggressive treatment can dramatically reduce admission rates for pain (Benjamin, Swinson, & Nagel., 2000; AHRQ, 2012). The University of Illinois Hospital & Health Sciences System Comprehensive Sickle Cell Center is one of the largest in the United States. The volume of acute medical care is very high in this urban hospital with an enrollment of approximately 750 patients, pediatric and adult. For fiscal year 2012 clinic volume for pediatrics and adults was 2566, in-patient volume was 886 and adult ED visits for pain were 867. To improve medical treatment, outcomes and satisfaction of sickle cell patients, the University Of Illinois Hospital & Health Sciences System Comprehensive Sickle Cell Center opened its Acute Care Center (ACC) in 2009.
One measure of the ACC's effectiveness is the TTFD of analgesic from patient's arrival to the ACC. Using the American Pain Society as a resource a target of 90% of patients' TTFD <60 minutes was identified. For fiscal year 2012 the ACC's achieved this goal in 76% of 217 encounters as compared to 29% of 867 encounters in the Emergency Department's (ED). Patient satisfaction in the ACC is closely related to TTFD. Since the first year of the ACC's operation, the volume of patients served in ACC has increased 52% and the ED volume has remained relatively unchanged. The ACC currently provides day hospital pain management services on weekdays, and will expand its hours to evenings and weekends.
Challenges for the ACC to meet its goal include timely registration of patients into the system by the admitting department and intravenous access. Challenges for the ED were the lack of awareness of TTFD goal, bed availability, triage speed and appropriate level of urgency. Results from a retrospective analysis in pediatric ED patients with sickle cell disease revealed average TTFD of 4 hours in 181 patients, however educating staff of TTFD goal in the pediatric ED resulted in lowering average TTFD to 1.5 hours in 16 patients.
In conclusion, exploration of TTFD as a quality measure revealed several areas for possible improvement in healthcare delivery for SCD. TTFD is quite new for some areas such as our ED, but as our preliminary data revealed that educating staff can cut TTFD by 50%. In addition, an analysis of hospital systems e.g. admitting registration processes is warranted, as well as exploring alternatives in addressing IV access. Nonetheless, the ACC is a preferable alternative to the use of conventional ED for the treatment of sickle cell pain because of its dedication to the management of sickle cell pain and subsequent reduction in hospital admissions.

Disclosures:
No relevant conflicts of interest to declare.