LOYOLA UNIVERSITY HEALTH SYSTEM

Loyola University Chicago

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

Sickle cell patients in the ED: small volume, LARGE PROBLEMS

Opportunity 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

Opportunity Knocks
Subjective nature of pain Opioid-tolerant patients Little use of adjunctive

agents Timeliness of assessment and treatment

Solutions Implemented
Convened a multi-disciplinary team General Medicine, Anesthesia Pain Service, Social Work, ED Physicians & Nurses Developed and implemented a focused

guideline Educated ED caregivers & patients Collaborated with General Medicine initiative for inpatient sickle cell management

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

Pain Assessment
Documentation of VAS
Percent Documented
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
100% 100% 94% 100% 100% 89% 70% 82%83% 75% 60% 87% 81%

VAS

70%

63%

Triage

After 1st Med

After 2nd Med

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

documentation improved at all time intervals Reassessment of pain after medication administration is an area that offers an opportunity for improvement

Pain Medications
Pain Medication Usage

Use of Dilaudid has

100%

97% 90.2% 86.3% 84% 76.7%

Percent Usage

80% 60% 40% 20% 0%

increased since guideline implementation Demerol utilization has decreased

14.6% 3.7% 0% 6.7% 0% 16% 8.5% 7.0% 3.7% 0%

Dilaudid

Morphine

Demerol

Baseline

Jul-02

Aug-02

Sep-02

Jan

Time to Treatment & LOS

Time-To-Treatment and ED Length of Stay
300 250
Minutes

Time to treatment

271 212

267 207

232

200 150 100 50 0 80 61 102 58 57

decreased from 80 to 57 minutes ED length of stay has decreased from 271 minutes to 232 minutes

Time to Rx Baseline Jul-02 Aug-02

LOS Sep-02 Jan

Adjunctive Effect of Toradol

Toradol Effects on Disposition
100% 80%

Patients that

60% 40% 20% 0%

66%

63%

33%

31%

Discharge to Home

Hospital Admission

received Toradol, in addition to opioid analgesics, were more likely to be discharged home from the ED, than admitted to the hospital

Percentage

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

Conclusions
Focused guideline usage has improved

care 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 toradol adjunct

Sickle Cell Guideline has proven to be a

useful resource for physicians managing pain in patients with Sickle Cell disease.

Next Steps
Continue utilization of guideline Further education of staff on

reassessment after pain medications and treatment of pain Increase utilization of toradol Refine guideline based on feedback Ongoing review of compliance to guideline