source: The American Society of Pediatric Hematology/Oncology

year: 2016

authors: Matthew Schefft, India Sisler, Caitlin Swaffar, Cady Ploessl, Jennifer Newlin, Robin Foster

Background:

Vaso-occlusive crisis (VOC) is a frequent event for children with sickle cell disease and creates a significant burden on emergency departments (ED). Previous reports showed decreased admission rates when individualized pain plans (IPP) are used in conjunction with day hospitals or sickle cell nurse practitioners embedded in the ED.

Objectives:

To reduce the admission rate for children with sickle cell disease presenting to our pediatric ED with VOC by >20% within six months of initiating IPPs.

Design/Method:

A quality improvement team was assembled including members of the hematology division, ED, and pharmacy. A Plan-Do-Study-Act (PDSA) format was employed. The IPP document was created in a unique folder within the electronic medical record. IPPs were initially created through retrospective chart review for our 80 highest resource users.

Pediatric residents, ED residents, and ED attending physicians were instructed on access to and use of the IPPs. Our study measured the presence of an IPP, adherence to the IPP, and time to second opiate dose administration. Our primary outcome was admission rate. Length of stay and 72-hour return to the ED was assessed as balancing measures.

Results:

IPPs were available for 73% of children with sickle cell disease who presented to our ED with VOC during the study period. The residents and attending physicians in the ED followed the IPP 84% of the time.

The average time to administration of a second opiate dose was 60 minutes (CI 46.6-73.4) among patients discharged from the ED compared to 111 minutes (C.I. 76.5-145.5, p 0.008) among patients admitted to the hospital. Admission rate was 39% once IPPs were initiated compared to 57% prior to implementation (p = 0.03). Overall, admission rate decreased by 33% among patients with an IPP compared with 2014 (p = 0.038). Average LOS decreased from 4.7 days in 2014 to 3.4 days since initiating IPPs. There was no difference in 72-hour return rate to ED.

Conclusion:

IPPs provide an effective strategy to reduce the admission rate for children with sickle cell disease presenting with VOC. Shorter time to second opiate dosing was also associated with a reduced risk of admission.

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