title: Improving the Management of Vaso-Occlusive Episodes in the Pediatric Emergency Department.
abstract: OBJECTIVE
  Vaso-occlusive episodes (VOEs) account for the majority of emergency department (ED) visits for children with sickle cell disease (SCD). We hypothesized that addressing key barriers to VOE care would improve receipt of analgesics and outcomes.
  
  
  METHODS
  A quality improvement (QI) initiative was conducted from September 2010 to April 2014 to streamline VOE care in an urban pediatric ED. Four interventions were used: a standardized time-specific VOE protocol; intranasal fentanyl as the first parenteral pain medication; an SCD pain medication calculator; and provider and patient/family education. Data were collected for 3 outcome measures (mean time from triage to first parenteral opioid and admission/discharge decision, and proportion discharged from the ED); 1 process measure (mean time from triage to initiation of patient-controlled analgesia); and 4 balancing measures (mean time from triage to second intravenous opioid dose, 24-hour ED readmission, respiratory depression, and length of stay).
  
  
  RESULTS
  There were 289 ED visits in the study period. Improvements were seen in mean time to: first dose of parenteral opioid (56 to 23 minutes); second opiate intravenous dose (106 to 83 minutes); admission and discharge decisions (163 to 109 minutes and 271 to 178 minutes, respectively); and initiation of patient-controlled analgesia (216 to 141 minutes). The proportion discharged from the ED increased from 32% to 48% (χ(2) = 6.5402, P = .01). No increase in 24-hour readmission, respiratory depression, or inpatient length of stay was observed.
  
  
  CONCLUSIONS
  Using VOE-specific interventions, we significantly improved VOE care for children. Studies are needed to determine if these results can be replicated.
authors.affiliation: Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts; and patricia.kavanagh@bmc.org.
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Kavanagh
authors.affiliation: Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts; and.
authors.forename: Philippa G
authors.initials: PG
authors.lastname: Sprinz
authors.affiliation: Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts; and.
authors.forename: Tahlia L
authors.initials: TL
authors.lastname: Wolfgang
authors.affiliation: Departments of Pharmacy.
authors.forename: Kelly
authors.initials: K
authors.lastname: Killius
authors.affiliation: Social Work, and.
authors.forename: Maria
authors.initials: M
authors.lastname: Champigny
authors.affiliation: Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts; and.
authors.forename: Amy
authors.initials: A
authors.lastname: Sobota
authors.affiliation: Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts; and.
authors.forename: David
authors.initials: D
authors.lastname: Dorfman
authors.affiliation: Nursing, Boston Medical Center, Boston, Massachusetts.
authors.forename: Karan
authors.initials: K
authors.lastname: Barry
authors.affiliation: Nursing, Boston Medical Center, Boston, Massachusetts.
authors.forename: Renee
authors.initials: R
authors.lastname: Miner
authors.affiliation: Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts; and.
authors.forename: James M
authors.initials: JM
authors.lastname: Moses
mesh_terms: D000281:Administration, Intranasal; D000293:Adolescent; D000700:Analgesics / Q000008:administration & dosage* / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000627:therapeutic use; D000755:Anemia, Sickle Cell / Q000150:complications*; D002648:Child; D002675:Child, Preschool; D004334:Drug Administration Schedule; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D010146:Pain / Q000188:drug therapy* / Q000209:etiology; D010353:Patient Education as Topic; D058996:Quality Improvement; D013997:Time Factors; D014218:Triage; D014652:Vascular Diseases / Q000209:etiology*; D055815:Young Adult
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid; D005283:Fentanyl