Evaluating Emergency Department Order Set in Sickle Cell Pain Management
Katherine Weller PharmD, Kanaan Shah PharmD, Christele Francois PharmD, BCPS, Tonya Hershman PharmD, BCPS, Karen Clarke, MD, Alexandra Arges MD, Mohamad Moussa MD, Yoo Mee Shin MD, Nicholas Kurtzman MD, Krista Dumkow PharmD, BCEMP, BCPS; Emory University Hospital, Atlanta, GA
Background:
Vaso-occlusive crises (VOC) in patients with sickle cell disease (SCD) occur because of adhesion of red blood cells to small vessel walls, leading to obstruction of blood flow, pain, and ischemia1. VOC is the most common complication of SCD. Patients often present to the emergency department (ED) for acute pain management when their home pain regimens fail to adequately control the crisis2. To manage acute crises, the American Society of Hematology Clinical Practice Guidelines on SCD recommend administering opioids within 60 minutes of arrival to the ED3. The guidelines further recommend a tailored opioid regimen that is reassessed every 30 to 60 minutes and multi-modal pain regimens with non-opioid therapies such as non-steroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants, or acetaminophen. This study aimed to assess the utilization of a guideline-based order set for acute pain management of patients with SCD presenting to the ED in a VOC.
Methods:
This was an Institutional Review Board-approved, single center, retrospective observational study of patients presenting to the ED with a diagnosis of VOC between January 1, 2024, and January 31, 2025. A total of 289 patients were identified and 181 met inclusion criteria of age >18, presentation during the study period, and a final diagnosis of VOC. Exclusion criteria included active infection, chronic or acute pain due to alternative diagnosis or other causes, history of substance abuse, left against medical advice, and pregnancy. The primary outcome was the incidence of analgesia administered within 60 minutes of ED arrival. Secondary outcomes included incidence of inpatient admission, time to initial dose of analgesia from arrival to the ED, time spent in the waiting room, pain re-assessment within 15-30 minutes of pain medication administration, dose escalation by 25% every 15-30 minutes until pain is adequately controlled, reduction in pain intensity measured by a pain scale, adverse events associated with opioid use, use of adjunctive NSAIDs, and ED length of stay.
Results:
Of the 181 patients that were included in this study, 37 patients had medications ordered utilizing the SCD order set in the ED. The primary outcome of incidence of analgesia administered within 60 minutes of ED arrival was not statistically significant (order set group, 10.8%; non-order set group, 11.8%; p-value=0.56). The use of NSAIDs was significantly higher in the orderset group (order set group, 43.2%; non-order set group, 16%; p-value=0.0003). Inpatient admission rates, pain assessment, dose escalation, and reduction in pain intensity were similar between groups, with no statistically significant differences. Operational metrics such as average time to analgesia, time spent in the waiting room, or average ED length of stay were not statistically significant. For adverse events associated with opioid use, there was no difference between groups (order set group, 8.11%; non-order set group, 1.39%; p-value=0.99). Of patients that had the order set used upon ED arrival, 70% had analgesics ordered through the order set panel.
Conclusions:
Implementation of the order set did not significantly improve the or timeliness of analgesia within 60 minutes of ED arrival. The greatest barrier to receiving analgesia within 60 minutes of ED arrival was delays in appropriate room placement and IV placement. Strategies to address this barrier include prioritizing triage for patients presenting with VOC and implementing bed prioritization protocols to expedite rooming. The order set promotes guideline driven, multimodal VOC management while further optimization is needed to enhance timely analgesia, pain reassessment, and operational metrics. Future efforts should educate providers about the order set and refine the order set to improve its effectiveness, such as ensuring that analgesics are ordered through the order set and enhance timely nursing communications for pain scores and dose escalation.
