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Sickle Cell Pain Management

in the Emergency Department

B. Probst, MD; J. Williams, RN;

D. Speed, RN, MSN; M. Cichon, DO;C. Jackson, MD; M. Pearlman, MS4

Loyola University Chicago

LOYOLA

UNIVERSITY

HEALTH SYSTEM

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Sickle cell patients in the ED:small volume, LARGE PROBLEMSOpportunity to

Improve:

Pain assessment Treatment of pain

Disposition

Desired Outcome:

Consistent pain

assessment &

documentation

Standardize

treatment

Expedite timely

disposition to

home or admission

to hospital

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Opportunity Knocks

Subjective nature of pain

Opioid-tolerant patients

Little use of adjunctive

agents

Timeliness of

assessment andtreatment

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Solutions Implemented Convened a multi-disciplinary team

General Medicine, Anesthesia Pain Service,Social Work, ED Physicians & Nurses

Developed and implemented a focusedguideline

Educated ED caregivers & patients

Collaborated with General Medicineinitiative for inpatient sickle cellmanagement

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Progress to Date

Guideline implemented July, 2002

Minor adjustments made to guideline after

feedback from Caregivers Identified and collected data measures:

Documentation of VAS

Analgesic usage

Adjunct usage

Time-to-treatment

Length-of-stay

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Pain Assessment

VASdocumentationimproved at all

time intervals Reassessment of

pain aftermedicationadministration is

an area that offersan opportunity forimprovement

Documentation of VAS

70% 70%

60%

100%

100% 89%

100%

75%

63%

100%

82% 81%

94%

83%87%

0%

10%

20%

30%

40%

50%

60%

70%80%

90%

100%

Triage After 1st Med After 2nd Med

Time Intervals

P

ercentDocumented

Baseline Jul-02 Aug-02 Sep-02 Jan-03

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Pain Medications

Use of Dilaudid has

increased since

guidelineimplementation

Demerol utilization

has decreased

Pain Medication Usage

3.7%

14.6%

97%

6.7%

84%

0%

16%

90.2%

3.7%

76.7%

8.5%

0% 0%

86.3%

7.0%

0%

20%

40%

60%

80%

100%

Dilaudid Morphine Demerol

PercentUsage

Baseline Jul-02 Aug-02 Sep-02 Jan

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Time to Treatment & LOS

Time to treatment

decreased from 80

to 57 minutes

ED length of stay

has decreased

from 271 minutes

to 232 minutes

Time-To-Treatment

and

ED Length of Stay

80

61

212

102

58

207

57

232271 267

0

50

100

150

200

250

300

Time to Rx LOS

Minutes

Baseline Jul-02 Aug-02 Sep-02 Jan

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Adjunctive Effect of Toradol

Patients that

received Toradol, in

addition to opioidanalgesics, were

more likely to be

discharged home

from the ED, than

admitted to thehospital

Toradol Effects on Disposition

31%

66% 63%

33%

0%

20%

40%

60%

80%

100%

Discharge to Home Hospital Admission

Disposition

Percentage

w-Toradol (N=20) w/o-Toradol (N=48)

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Conclusions

Focused guideline usage has improvedcare for sickle cell patients in the ED: Improved pain assessment

Decreased time to treatment & length-of-stay

Decreased demerol usage

Increased discharge to home with toradoladjunct

Sickle Cell Guideline has proven to be auseful resource for physicians managingpain in patients with Sickle Cell disease.

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Next Steps

Continue utilization of guideline

Further education of staff onreassessment after pain medications and

treatment of pain Increase utilization of toradol

Refine guideline based on feedback

Ongoing review of compliance toguideline