Department of Anesthesiology and Pain Service Line.
Department of Emergency Medicine.
Pain Med. 2022 Dec 1;23(12):2050-2060. doi: 10.1093/pm/pnac096.
Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD.
A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use.
There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792.
Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.
与镰状细胞病（SCD）相关的疼痛会导致严重的并发症，并频繁导致急诊就诊。SCD 患者在急诊就诊时经常报告疼痛治疗不足，导致住院。对一项旨在规范 SCD 相关疼痛患者急诊就诊护理的质量改进项目进行了回顾性分析。
进行了为期 3 年的前瞻性质量改进计划。我们的多学科提供者团队在 2019 年实施了一个 ED 医嘱集，以改善护理并提供充分的镇痛管理。我们的主要结果是干预后患者的总体住院率。次要结果指标包括 ED 处置、72 小时内返回 ED 的比率、入院和出院时的 ED 疼痛评分、ED 治疗时间、住院时间、非阿片类药物的使用和阿片类药物的使用。
实施医嘱集后，住院率总体下降了 67%（P=0.005），且每月的住院率百分比逐月下降（P=0.047）。首次使用非阿片类镇痛药的时间减少了 71 分钟（P>0.001），但首次使用阿片类药物的时间没有变化。72 小时内返回 ED 的比率保持不变（7.0%对 7.1%）（P=0.93），ED 逃跑率保持不变（1.3%对 1.85%）（P=0.93）。实施后，口服对乙酰氨基酚（7%）、塞来昔布（1.2%）和替扎尼定（12.5%）和静脉注射氯胺酮（30.5%）和酮咯酸（27%）的处方量显著增加。住院和非住院患者出院时的 ED 疼痛评分均无变化（住院患者：7.12 对 7.08）（P=0.93）和非住院患者：5.51 对 6.11）（P=0.27）。在 12 个月的观察期内，确定潜在的成本降低了 193440 美元，每次就诊的平均费用降低了 792 美元。
使用标准化和多模式 ED 医嘱集可降低住院率和镇痛的及时性，而不会对患者的疼痛产生负面影响。
