Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University and Massey Cancer Center, Richmond, Virginia, USA.
Virgnia Commonwealth University School of Medicine, Richmond, Virginia, USA.
Pediatr Blood Cancer. 2018 Oct;65(10):e27274. doi: 10.1002/pbc.27274. Epub 2018 Jun 1.
Vaso-occlusive crisis (VOC) is frequent in children with sickle cell disease (SCD) creating significant burden on patients, families, and emergency departments (ED). The objective of the project was to reduce the admission rate for children with SCD presenting to our ED with VOC by >20% within 6 months of initiating individualized pain plans (IPP).
A multi-disciplinary quality improvement team was assembled. A Plan-Do-Study-Act (PDSA) format was employed. The IPP document was created in a unique folder within the electronic medical record. IPPs were created through retrospective chart review for our 80 highest resource users. Pediatric residents, ED residents, and ED attending physicians were instructed on use of the IPPs. Our study measured the presence of an IPP, adherence to the IPP, and time to opiate administration. Our primary outcome was admission rate. Length of stay and 72-hr return to the ED were assessed as balancing measures.
Overall, admission rate decreased by 24% following implementation compared with the previous 5 years (P = 0.046). IPPs were created for 78% of patients and followed by ED staff in 86% of visits. Admission rate was significantly lower for patients receiving a second opiate dose within 45 min of the first dose (P < 0.01). There was no difference in readmission rate or 72-hr return rate to ED.
This study presents an effective strategy to reduce admission rate for children with SCD presenting with VOC. Shorter time to second opiate dosing was also associated with reduced risk of admission.
镰状细胞病（SCD）患儿经常发生血管阻塞危象（VOC），给患者、家庭和急诊科（ED）带来了巨大负担。该项目的目的是在启动个体化疼痛计划（IPP）后的 6 个月内，将因 VOC 就诊于 ED 的 SCD 患儿的入院率降低 20%以上。
组建了一个多学科质量改进团队。采用计划-执行-研究-行动（PDSA）模式。IPP 文件在电子病历中的一个独特文件夹中创建。通过对我们 80 名资源消耗最高的患者的回顾性图表审查，创建了 IPP。儿科住院医师、ED 住院医师和 ED 主治医生接受了使用 IPP 的培训。我们的研究测量了 IPP 的存在、对 IPP 的依从性以及阿片类药物给药的时间。我们的主要结果是入院率。住院时间和 72 小时内返回 ED 的情况作为平衡措施进行评估。
与前 5 年相比，实施后总体入院率降低了 24%（P=0.046）。78%的患者创建了 IPP，86%的就诊患者接受了 ED 工作人员的随访。在首次给药后 45 分钟内给予第二剂阿片类药物的患者，其入院率显著降低（P<0.01）。再入院率或 72 小时内返回 ED 的比率没有差异。
本研究提出了一种有效策略，可降低因 VOC 就诊于 ED 的 SCD 患儿的入院率。第二剂阿片类药物给药时间更短也与降低入院风险相关。
