A Multiyear Cross-sectional Study of Guideline Adherence for the Timeliness of Opioid Administration in Children With Sickle Cell Pain Crisis

Abstract

Study objective: The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network. Methods: We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5 C (101.3 F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years. Results: A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P<.001). There was no change in timeliness to first dose or time between doses across years (P>.05 for both). Conclusion: Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.

Adherence to NHLBI guidelines for the emergent management of vaso‐occlusive episodes in children with sickle cell disease: A multicenter perspective

“…Parenteral opioids remain the mainstay of treatment for SCD‐VOE. Our observation of poor guideline adherence to administer timely initial parenteral opioids aligns with those in prior studies 2 . Furthermore, the majority of patients failed to receive timely administration of a second dose of parenteral opioids within 30 min of the first.…”

“…Patients with sickle cell disease (SCD) commonly experience vaso‐occlusive pain episodes (VOE), which accounts for 78% of all emergency department (ED) visits among patients with SCD 1 . SCD‐VOE pain is often under‐, and inconsistently, treated in the ED 2 . In 2014, the National Heart, Lung, and Blood Institute (NHLBI) put forth guidelines to direct the care of patients presenting with VOE 3 .…”

“…1 SCD-VOE pain is often under-, and inconsistently, treated in the ED. 2 In 2014, the National Heart, Lung, and Blood Institute (NHLBI) put forth guidelines to direct the care of patients presenting with VOE. 3 Key guideline recommendations include: (1) triage as high priority with rapid evaluation of patients presenting with VOE, (2) use of parenteral opioids for moderate-to-severe pain with administration ≤30 min after ED triage or ≤ 60 min after registration, (3) pain reassessment…”

“…Our observation of poor guideline adherence to administer timely initial parenteral opioids aligns with those in prior studies. 2 Furthermore, the majority of patients failed to receive timely administration of a second dose of parenteral opioids within 30 min of the first. The creation of personalized pain management plans, use of intranasal medications including fentanyl, diamorphine, or hydromorphone, and allowing nurseinitiated administration of parenteral opioids in these plans may shorten the time to parenteral opioid administration.…”

Return visit rates after an emergency department discharge for children with sickle cell pain episodes

“…[11][12][13] Consistent with the goal of improved ED care decreasing hospitalizations, a single-site study showed guideline-adherent care decreased hospitalization for children experiencing acute pain episodes. 14 While current research indicates ED care is delayed 15,16 and many individuals with SCD are not satisfied with the care they receive, 17,18 there are no data regarding post-ED care quality. However, if guideline-adherent ED care is provided and results in decreased hospitalization, it is essential to determine if this care results in more patients returning to the ED after being discharged home.…”