Introduction: The American Society of Hematology and National Alliance of Sickle Cell Centers recommend individualized care plans (ICPs) for use in acute care settings to meet specific needs of individuals with sickle cell disease (SCD). Since 2020, we have standardized the approach to pain management in the emergency department (ED) and created ICPs for patients seen in our SCD clinics. For the first time, to our knowledge, we report on the clinical impact of ICPs in the ED. We hypothesized that ICPs improve quality of care as measured by improvement in pain scores, admission rates, time to first opioid analgesic and ED length of stay (LOS). We also hypothesized that standardization of pain management protocols in our ED improved outcomes for all patients regardless of ICP availability.

Methods: As part of the ED ALIGN study, ICPs were implemented starting in October 2020. We queried all ED visits at our center between October 2019 and June 2024 and included encounters for patients with SCD known to the pediatric or adult SCD clinics at our institution and who received at least one opioid analgesic. Patients with plans limiting opioids (n=5) or who had undergone stem cell transplant (n=7) were excluded. We recorded pain scores, final disposition and times of ED arrival, discharge, decision for disposition, and analgesic administration. Demographic data including sex, genotype and age were obtained. Chart review identified the date an ICP was created. The primary predictor of interest was the presence of an ICP at the time of the ED encounter. Primary outcomes were ED disposition, likelihood of achieving a clinically significant improvement in pain score (>2 points), time to first opioid, and ED LOS. We also evaluated each of these outcomes over time. Statistical analyses were done in Stata 16. Logistic and linear regression were used for binary and continuous outcome variables, respectively.

Results: From October 2019 to June 2024, 146 patients (94 HbSS, 29 HbSC, 7 HbSB0, 16 HbSB+) had 1195 ED encounters with a median of 3 encounters per patient (range 1-128, IQR 1-9). The proportion of encounters with an active ICP increased from 0% in 2019 to 70% in 2024.

Encounters with ICPs had a 76% higher likelihood of achieving a clinically significant pain score improvement (p<0.001). From 2019 to 2024, the proportion of encounters with such improvement increased from 40.3% to 66.1% overall, with improvement to 73.4% in those with ICPs and 48.3% in those without ICPs. By disposition, 60.7% of all discharged patients reported significant pain score improvement in 2019 versus 82% of encounters with an ICP and 70% of encounters without ICP by 2024. For admitted patients, significant pain score improvement increased from 20.6% in 2019 to 61.1% with ICPs and only 23.5% without ICPs by 2024.

Encounters with ICPs were significantly shorter than those without an ICP (302 min vs 360 min p<0.001). For admitted patients, ED LOS was 74 minutes shorter when an ICP was available (p=0.0003) and for those who were discharged, ED LOS was 44 minutes shorter when an ICP was available (p=0.015).

Admission rates declined from 2019 to 2024 (50.8% → 43.1%), though the change was not statistically significant and did not differ between patients with and without ICPs. . There was no difference in likelihood of receiving first opioid within 60 minutes of arrival between those with or without ICPs (44.6% vs 47.3%). Overall, likelihood of receiving first opioid within 60 minutes decreased over the study period from 59.6% in 2019 to 39.5% in 2024. This decline from baseline (59.6%) was smaller for those with ICPs compared with those without ICPs (47.1% vs 21.6%)

Discussion: In this real-world study, we found that while ICPs did not change the likelihood of admission or rapid receipt of opioids, ICPs significantly improved pain scores and reduced ED LOS. Furthermore, improvements were noted over time for both patients with and, to a lesser extent, without ICPs. These findings suggest that standardization of care enhances ED pain management regardless of the existence of an ICP for an individual patient. The lack of change in admission rates may be multifactorial and possible confounders and mediators such as genotype, sex, age and frequency of acute care utilization will be assessed in future analyses. The COVID-19 pandemic may also have had an impact on outcomes. Together, our data demonstrate the value of ICPs in improving acute care for individuals with SCD.

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2025
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