https://orcid.org/0000-0002-7723-8936
Key Points
Standardized ED pain protocols with intranasal fentanyl improve time to first analgesia dose in pediatric patients with SCD pain.
Protocol implementation was associated with a reduction in hospital pain admission rates.
Sickle cell disease (SCD) is an inherited red blood cell disorder with significant complications, including vaso-occlusive pain crisis (VOC), the most common cause of emergency department (ED) visits and hospitalizations. Pain in children with SCD is often underestimated. We evaluated the impact of a standardized institutional nurse-initiated ED SCD pain protocol, employing intranasal (IN) fentanyl as the initial agent, on hospital admission rates. We conducted a pre/post-intervention study of patients with SCD (ages 0-21 years) presenting to a quaternary pediatric ED for uncomplicated VOC pain from June 2015 to December 2019. In the pre-intervention period, 162 patients accounted for 471 ED visits, while 80 patients accounted for 162 visits in the post-intervention period. Post-intervention, hospitalization rates (p=0.0017) and inpatient length of stay (p=0.0019) decreased, while median pain scores at presentation (p=0.0047) and discharge (p=0.1451) remained comparable. The time to initial analgesia dose significantly improved in the post-intervention (p<0.0001), along with the time from physician order to initial analgesia administration (p=0.0005). Intravenous and IN analgesia use rose significantly in the post-intervention (OR=4.7, p<0.0001), with IN fentanyl (INF) being the preferred analgesic agent (61%) and a corresponding reduction in oral analgesic use (p<0.0001). In an ad hoc sustainability analysis, INF use remained high and time to first dose was sustained. Implementing a standardized ED SCD pain protocol improved timeliness and consistency in analgesia administration and decreased overall hospitalization rates. This study also highlights the role of INF as an effective initial analgesic within standardized ED protocols for pediatric VOC.
