Addressing institutional barriers in sickle cell pain management: A resident-led quality improvement study Free

Sickle Cell Disease (SCD) affects over 100,000 individuals in the U.S., with vaso-occlusive crises (VOC) being the leading cause of emergency department visits and hospitalizations. Nationally, SCD patients report pain approximately 51% of the time. In Louisiana, 1,430 patients with SCD were hospitalized in 2023, with 96% identifying as African American, reflecting significant racial health disparities. Despite 2020 American Society of Hematology (ASH) guidelines emphasizing rapid triage, individualized opioid regimens (particularly for patients on chronic opioid therapy), multimodal pain control, and regular mental health screening, implementation remains inconsistent. At our tertiary care center, we encounter frequent SCD admissions for pain, often within 30 days of discharge, with prolonged hospital stays and frequent dissatisfaction with pain control.

This quality improvement (QI) project assessed resident knowledge and practice patterns in SCD pain management and implemented targeted educational interventions to improve adherence to ASH guidelines and established institutional opioid dosing protocol.

We conducted a QI initiative among internal medicine and med-peds residents at a tertiary care academic center from March-May 2025. A 16-item pre-intervention survey assessed baseline practices in adult SCD pain management, including awareness of institutional protocols, opioid tailoring for patients on chronic opioids, use of multimodal therapies, and routine mental health screening.

• A 45-minute resident-led presentation on ASH 2020 guidelines and institutional practices,

• Distribution of practice guideline handouts and opioid conversion charts 15 days later,

• Visual displays of materials in resident workrooms and hospital medicine team rooms.

A 15-item post-intervention survey was administered 30 days after handout distribution. McNemar's test was used for statistical analysis.

Thirty residents completed the pre-intervention survey and 25 completed the post-intervention survey. Significant improvements were observed in awareness of the institutional opioid dosing protocol (30% vs. 70%, p<0.01), tailoring opioid regimens based on chronic baseline use and prior response (40% vs. 65%, p=0.02), routine mental health screening (27% vs. 57%, p<0.01), and comfort advocating for appropriate pain control (20% vs. 50%, p=0.01). A non-significant trend toward increased use of non-opioid pharmacologic adjuncts was noted (47% vs. 57%, p=0.08). No change was observed in interdisciplinary collaboration (60% pre- and post-). Reported patient length of stay remained similar (majority reporting 3–5 days: 66.7% pre- vs. 75% post-intervention, p=0.67).

Persistent barriers included concern about drug-seeking behavior (85%), discomfort with high-dose opioid prescribing (90%), limited attending physician support (30%), and inadequate access to pain management consultation (25%). Residents identified key resources to improve care: streamlined opioid protocols (100%), additional education on opioid safety (75%), workshops addressing bias and stigma (50%), integration of dosing tools into the EMR (25%), and access to pain consult services (25%).

A brief, resident-led educational QI initiative significantly improved awareness and application of key SCD pain management practices, including individualized opioid use and mental health screening. However, persistent institutional and attitudinal barriers—such as stigma, discomfort with high-dose opioid prescribing, and attending physician discomfort despite institutional protocol—limit full adoption of guidelines.

Sustained improvement will require standardized opioid protocols, interprofessional collaboration, recurring education for trainees and hospitalists, integration of decision support tools into the EMR, and development of outpatient and acute day care pathways. Future efforts should also include hematology faculty engagement and stigma-reduction initiatives to foster a more supportive clinical environment.