Use of Emergency Severity Index 2 Reduces Time to First Analgesia in Sickle Cell Disease Vaso-occlusive Crisis Open Access

• Patients with sickle cell disease in vaso-occlusive crisis are often under-triaged resulting in poor adherence to pain management guidelines

• Emergency Severity Index (ESI) is a major determinant of analgesic timing. Appropriate ESI assignment of 2 reduces time to first analgesia.

Guidelines from the National Heart, Lung, and Blood Institute recommend assigning an Emergency Severity Index (ESI) acuity level 2 to patients with sickle cell disease (SCD) presenting to the emergency department (ED) with vaso-occlusive crisis (VOC) and administering analgesia within 30 minutes of triage or 60 minutes of registration. The American Society of Hematology guidelines recommend analgesia within 60 minutes of ED arrival. In this study of adult patients with SCD presenting to the ED with uncomplicated VOC between April 1 and September 30, 2023, we compared time from triage to administration of first analgesia (TTFA) and time to second analgesia administration (TTSA) for those who were assigned ESI 2 versus 3. Sixty-six visits were included in the analysis. Median pain score at triage was 9/10 (range, 6-10). ESI 2 was assigned to 23 visits (34.8%) and ESI 3 to 43 (65.2%). Four patients assigned ESI 3 left the ED without receiving analgesia. For the remaining 62 patients, median TTFA was 65 minutes for those assigned ESI 2 and 178 minutes for those assigned ESI 3 (P < 0.001), while median TTSA did not differ (72 versus 78 minutes; P = 0.485). In a Cox regression analysis including age, gender, SCD genotype, pain score at presentation and ESI acuity level, only ESI correlated with TTFA (HR 5.731, P < 0.001). System-based interventions to ensure assignment of ESI 2 can improve adherence to evidence-based guidelines regarding prompt analgesia for patients with SCD presenting to an ED for VOC.