Introduction: Painful vaso-occlusive episodes (VOE) are the most common complication prompting emergency care in patients with sickle cell disease (SCD). The National Heart, Lung, and Blood Institute recommends assigning an Emergency Severity Index (ESI) of 2 to SCD patients presenting with VOE and delivering the first analgesic dose within 30 minutes of triage (or 60 minutes from registration), underscoring the need for timely triage and early intervention. Timeliness to pain management is also under consideration by CMS as a quality metric. This initiative aimed to evaluate and improve triage patterns for SCD patients across the Atrium Health system by assessing ESI scoring trends and providing targeted education.

Methods: We retrospectively analyzed ESI levels assigned to SCD patients from January 2024 to July 2025. ESI is a validated 5-level triage tool used nationwide. We collected demographic data, chief complaints, ESI assignments, and dispositions. In November 2024, based on initial findings, we introduced targeted education for triage clinicians, including symptom checklists, VOE-focused training modules, reinforced access to EMR-based individualized care plans, and awareness of local SCD resources in North Carolina. ESI Level 2 triage rates before and after intervention were compared.

Results: Between September 2023 and July 2025, 6555 SCD related ED visits were recorded, of which 4237 encounters were included in this study. Patients in this cohort had a median age of 26 years [SD 12 years] and were 95% self-identified as African American in ethnicity. 56% of patients were female.

On retrospective review of ED visits between January and October 2024, 2390 patients evaluated, 979 (41%) received ESI 2, while 1,371 (57%) were assigned ESI 3 status. After the delivery of targeted educational intervention, we analyzed the triage patterns from January to July 2025 that showed a sizeable improvement to 1122 [61%] ESI Level 2 assignments and 694 [38%] to ESI Level 3

On stratifying by location, of the 34 EDs that participated in the study, only 9 were still designating a higher proportion of SCD patients presenting with VOE to ESI 3 over ESI 2. A paired samples t-test was used to compare the triage assignment of ESI Level 2 ED admissions before and after the administration of education, with a p-value of 0.000004 suggesting statistically significant improvement in ED care delivery from a VOE triage perspective

Conclusion: Prior studies show that effective triaging of VOC in the ED can lead to earlier assessments and timely, evidence-based care for SCD patients presenting with VOE. This quality initiative, a collaboration between ED clinicians and the sickle cell clinic, led to significant improvements in ESI level assignments after targeted education.

VOEs remain a major cause of ED visits among SCD patients. A recent study found that super-high ED use (>33 visits/year) is linked to higher mortality compared to moderate use. Contributing factors include disease burden, social determinants, mental health issues, and limited outpatient access. High ED use and chronic opioid therapy may also influence provider perceptions of opioid dependence, delaying care. From the patient's perspective, delays in triage and intervention discourage seeking of timely treatment.

Moving forward, we will direct additional educational efforts to triage nurses and clinicians at the nine EDs identified as outliers. By enhancing provider knowledge and offering tools for accurate triage and management, we aim to reduce bias, improve care equity, deliver high-value care, and ultimately lower SCD-related morbidity and mortality across our system. In addition to targeted education, we also highlight the need for evaluation of sustained execution of appropriate triage.

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2025
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