A Standardized Emergency Department Order Set Decreases Admission Rates and In-Patient Length of Stay for Adults Patients with Sickle Cell Disease

Abstract

Introduction: Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD.

Methods: A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use.

Results: There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792.

Conclusions: Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.

Keywords: Admission; Emergency Department; Nociplastic Pain; Protocol; Sickle Cell Disease.

Figure 1.

Three-step ED algorithm for breakthrough pain related to SCD. PO= oral administration; IV= intravenous administration.

Figure 2.

ED SCD pain order set. PO= oral administration; IV= intravenous administration.

Figure 2.

ED SCD pain order set. PO= oral administration; IV= intravenous administration.

Figure 3.

ARIMA plot of admission rate per month. Red line depicts the actual admission rate. Blue line represents predicted admission rate. Black vertical line displays when the intervention took place in May of 2019.

Figure 4.

ARIMA plot of ED LOS per month. Red line depicts the actual ED LOS. Blue line represents predicted ED LOS. Black vertical line displays when the intervention took place in May of 2019.

Figure 5.

ARIMA plot of inpatient LOS per month. Red line depicts the actual inpatient LOS. Blue line represents predicted inpatient LOS. Black vertical line displays when the intervention took place in May of 2019.