Background: Children with sickle cell disease (SCD) are at increased risk for serious bacterial infections due to functional asplenia. Fever in this population is considered a medical emergency requiring rapid evaluation and empiric antibiotics. Guidelines recommend prompt antibiotic administration, while the literature specifically supports delivery within 60 minutes of emergency department (ED) arrival. However, achieving this target is often hindered by ED crowding and limited bed availability. To address this, the Children’s Hospital of Georgia (CHOG) pediatric ED implemented a nurse-driven sickle cell fever triage protocol. This study aims to evaluate whether protocol implementation improved the proportion of patients receiving antibiotics within 60 minutes.
Methods: This is a single-center, retrospective study conducted in the CHOG pediatric ED evaluating a nurse-first sickle cell fever triage protocol with reiteration on May 21, 2025, which allowed triage nurses to obtain IV access, labs, cultures, and notify a provider prior to room assignment. Patients 0–17 years with sickle cell disease who presented to the ED with fever (≥38°C) from November 2, 2024 to October 31, 2025 were included. Encounters with missing key time points or adult ED admissions were excluded. The primary outcome was the proportion of patients receiving antibiotics within 60 minutes of ED arrival. Secondary outcomes included frequency of protocol use and time from arrival to provider evaluation. Outcomes were compared between pre- and post-implementation periods using descriptive statistics, chi-square tests, and t-tests, as appropriate.
Results: A total of 52 patients were included in this IRB-approved study, with 31 in the pre-protocol group and 21 in the post-protocol group. Antibiotics were administered within 60 minutes of ED arrival in 3 patients (9.7%) in the pre-protocol group and 2 patients (9.5%) in the post-protocol group (p = 0.9853). The sickle cell with fever triage protocol was utilized in 1 (3.23%) of pre-protocol encounters compared with 4 (19.05%) of post-protocol encounters (p = 0.0576). The mean time from ED arrival to provider evaluation significantly decreased from 55 minutes in the pre-protocol period to 23 minutes in the post-protocol period (p = 0.0031).
Conclusions: This study found no significant difference in the proportion of patients receiving antibiotics within 60 minutes of ED arrival between the pre- and post-protocol groups at a single institution. There was a significantly faster time to provider evaluation in the post-protocol group, suggesting improved early recognition and prioritization of this high-risk population. While protocol utilization increased in the post-implementation period, it remained relatively low, highlighting the need for further workflow optimization, staff education, and system-level support to enhance adherence. Future efforts should focus on identifying barriers to timely antibiotic administration, particularly challenges with obtaining IV access in this population, and improving consistent protocol activation to better align care with national guidelines and ultimately improve outcomes for children with sickle cell disease presenting with fever.
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