1. 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

2. 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

3. Opportunity Knocks Subjective nature of pain Subjective nature of pain Opioid-tolerant patients Opioid-tolerant patients Little use of adjunctive agents Little use of adjunctive agents Timeliness of assessment and treatment Timeliness of assessment and treatment

4. Solutions Implemented Convened a multi-disciplinary team Convened a multi-disciplinary team –General Medicine, Anesthesia Pain Service, Social Work, ED Physicians & Nurses Developed and implemented a focused guideline Developed and implemented a focused guideline Educated ED caregivers & patients Educated ED caregivers & patients Collaborated with General Medicine initiative for inpatient sickle cell management Collaborated with General Medicine initiative for inpatient sickle cell management

5. Progress to Date Guideline implemented July, 2002 Guideline implemented July, 2002 Minor adjustments made to guideline after feedback from Caregivers Minor adjustments made to guideline after feedback from Caregivers Identified and collected data measures: Identified and collected data measures: –Documentation of VAS –Analgesic usage –Adjunct usage –Time-to-treatment –Length-of-stay

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

7. Pain Medications Use of Dilaudid has increased since guideline implementation Use of Dilaudid has increased since guideline implementation Demerol utilization has decreased Demerol utilization has decreased

8. Time to Treatment & LOS Time to treatment decreased from 80 to 57 minutes Time to treatment decreased from 80 to 57 minutes ED length of stay has decreased from 271 minutes to 232 minutes ED length of stay has decreased from 271 minutes to 232 minutes

9. Adjunctive Effect of Toradol Patients that received Toradol, in addition to opioid analgesics, were more likely to be discharged home from the ED, than admitted to the hospital Patients that received Toradol, in addition to opioid analgesics, were more likely to be discharged home from the ED, than admitted to the hospital

10. ConclusionsConclusions Focused guideline usage has improved care for sickle cell patients in the ED: 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. Sickle Cell Guideline has proven to be a useful resource for physicians managing pain in patients with Sickle Cell disease.

11. Next Steps Continue utilization of guideline Continue utilization of guideline Further education of staff on reassessment after pain medications and treatment of pain Further education of staff on reassessment after pain medications and treatment of pain Increase utilization of toradol Increase utilization of toradol Refine guideline based on feedback Refine guideline based on feedback Ongoing review of compliance to guideline Ongoing review of compliance to guideline