PURPOSE AND REVIEW OF LITERATURE
Despite improving survival rates for sickle cell disease (SCD),1 vaso-occlusive episodes (VOEs) remain inadequately managed. As a result, patients suffer needlessly from uncontrolled acute pain.2
SCD is an inherited blood disorder that is characterized by acute pain episodes. Sickled red blood cells clump and attach to the walls of blood vessels, leading to vessel obstruction and ischemia, which, in turn, cause tissue hypoxia and intense pain. VOEs, the clinical hallmark of SCD, are the most common reason for emergency department (ED) visits and admissions for this population.3
SCD affects approximately 100 000 Americans,4 and an additional 3 million carry the sickle cell trait.5 From 1989 to 1993, an average of 75 000 hospitalizations occurred in the United States because of SCD, incurring approximately $475 million in medical costs.4 Higher rates of resource utilization among SCD patients were found among those aged 18 to 30 years.6 Rehospitalization rates at 30 days for SCD are 30% to 47%, and 14-day rates are 22.1%.7
Negative experiences in hospital
Patients with VOEs have reported significant negative hospital experiences, characterized by significant delays in pain control, mistrust, stigmatization, lack of autonomy over one's treatment, negligent care, poor monitoring of vital signs, and lack of psychosocial support.2,8
Inadequate acute pain management for SCD stems partly from problems in the patient-provider relationship regarding this disease. Prejudice about drug abuse leads to disagreements between ED medical providers and SCD patients—53% of ED physicians and 23% of hematologists believed that more than 20% of SCD patients were addicted to narcotics and were disinclined to administer high-dose, parenteral opioids due to fears about the patient's narcotics addiction.9,10 However, the prevalence of opioid addiction in SCD patients is 2%—lower compared with addiction in other chronic pain syndromes.11 Negative attitudes from providers and lack of knowledge have been identified as critical barriers to effective pain management in SCD and have led to poor adherence to current analgesic protocols.12
Rapid pain management within 30 minutes from triage for VOEs is a well-supported evidence-based guideline for treating this population.13 Yet, despite the literature in support of this standard of care, health care teams remain nonadherent, leading to inadequate pain management of SCD patients. Although this quality improvement (QI) study was conducted in the United States, it is applicable to practices worldwide because inadequate management of VOEs in patients with SCD is a global issue.14,15
Current guidelines and recommendations
A plethora of clinical guidelines exist regarding VOEs in patients with SCD. The clear and consistent message of these guidelines is that VOEs in patients with SCD require rapid assessment, evaluation, administration of analgesics, and initial pain control to be performed within 30 minutes of triage.3,14–23
Current evidence has demonstrated statistically significant outcomes for SCD patients with triage guidelines, fast-track algorithms, ED-based pain protocols, standardized ED analgesic protocols, and use of clinical pathways. The success of these interventions depends on the education of patients, nurses, and health care providers. The outcomes of these interventions include improved pain management, hospital revenue, utilization of primary care clinics, and compliance with standard practice patterns and reduced admissions, length of stay (LOS), repeat ED visits, and 30-day readmission rates.6,17,24–30 Consequently, developing a set of quality measures and implementing evidence-based practice (EBP) clinical guidelines have the potential to improve health outcomes of SCD.31,32
The purpose of this QI study was to improve the timeliness of pain management for adult patients with SCD who are experiencing VOEs by translating EBP guidelines and recommended best practices into action-oriented standard care. The aims of the project were to decrease the time from triage until the first analgesic administration, increase patient satisfaction regarding acute pain control, and expedite patient flow by implementing an evidence-based practice standard care (EBPSC)—a visual algorithm flowchart for patients with VOEs.
Setting and participants
The implementation site was an urban academic tertiary medical center urgent care (UC) unit. The inclusion criteria were as follows: age 18 years or greater with a final diagnosis of SCD crisis (ICD-10 code D57.00, D57.219, or ICD-9 code 282.62) and treatment with analgesics of patients while in the UC center without regard to their final disposition (admitted or discharged). The exclusion criteria were age less than 18 years or chief complaint unrelated to VOEs in patients with SCD. The patient sample size was estimated by data abstraction from a prior study27 using the following assumptions: μ (0) = 293 “known” mean value for SCD population; μ (1) = 236 “expected” mean” value from sample; σ (standard deviation) = 154 for the population; 2-sided test; α = .05; and β = .8. A sample of 58 patients per group was required to estimate a difference in time to initial administration of analgesic of 30 minutes and in LOS from triage to disposition in the UC center.
This QI study was reviewed by the institutional review board at the implementation site and granted a waiver from informed consent on June 25, 2015.
The EBPSC (Figure 1), including computerized triage order sets, was developed and implemented on July 31, 2015. The 6-month period from July 31, 2014, to January 31, 2015, served as the historical control (“pre”), and another 6-month period, July 31, 2015, through January 31, 2016, was defined as the intervention period (“post”). The study used the same 6-month period in 2 consecutive years (2014 and 2015) to account for any seasonal confounding variables. Staff members attended 7 formal education workshops and informal meetings to facilitate their understanding of the action-oriented EBPSC before and during implementation of the EBPSC. S. K. conducted 10- to 15-minute educational lectures during the monthly staff meeting with PowerPoint presentations, storyboards, academic handouts, and posters from March 2015 to March 2016. S. K. provided 3 formal education sessions with a 30- to 60-minute PowerPoint presentation during provider meetings before and after the EBPSC implementation and several informal face-to-face educational sessions during the S. K.'s working hours.
A prospective pre-/postevaluation design was used to compare postimplementation outcomes with a preimplementation convenience sample of patients 18 years or older who presented with VOEs in the UC center. A retrospective review of the electronic medical records (EMRs) of patients with VOEs compared mean waiting time from triage to the first analgesic administration and the mean LOS in the UC center during 6 months preimplementation versus 6 months postimplementation of the EBPSC. Data were collected through a pre- and postevaluation survey of SCD patients to assess their satisfaction with the level of pain control and through analogous surveys of staff and providers to assess attitude and awareness of EBPSC.
A 16-item preevaluation provider survey and a 13-item preevaluation staff survey were developed by the S. K. and adapted from existing evidence.19 The surveys included questions regarding demographics, practice patterns, awareness of EBP guidelines, and attitudes toward the population with SCD. To measure providers' and staff members' attitudes, the S. K. administered 2 previously validated items from the Positive Provider Attitudes Toward Sickle Cell Patients Scale. Haywood et al28 reported good reliability (Cronbach α = 0.76-0.89) on attitude items. A 9-item postevaluation provider and staff survey consisted of items from the preevaluation survey to measure differences in practice patterns and attitudes toward SCD patients after implementing the EBPSC. Postevaluation surveys for providers and staff included questions regarding demographics (4 items), awareness of EBP guidelines (4 items), and attitudes toward the population with SCD (1 item). S. K. also developed a 9-item survey of SCD patients' UC center experiences, based on a literature review of acute pain management in the ED. The patient survey was a 9-item Likert-based scale (5 = very satisfactory; 4 = satisfactory; 3 = fair; 2 = low; 1 = very low), covering demographics (3 items) and experience with acute pain management in the UC center (6 items).
Data collection began on July 31, 2014, and lasted through January 31, 2016. The list of patients with VOEs in the UC center was retrieved from the coding Department of Family Medicine. Pertinent data were abstracted from the patient's EMR. In addition, pre- and postevaluation surveys of SCD patients, nursing staff, and providers were collected. All surveys were anonymous. Web-based survey software, Survey Monkey, and paper surveys were used for the providers and staff.
Patients' surveys were collected through a Web-based survey software, Survey Monkey, and paper surveys at community SCD support group meetings, the bedside, and the outpatient SCD clinic.
Data were analyzed using IBM Statistical Package for Social Sciences (Chicago, Illinois), version 22.0, for Windows. To assess the accuracy of data entry by the S. K., O. K. reviewed the charts independently. Descriptive statistics were generated for all categorical and continuous variables for the pre- and postimplementation groups. The independent t test and the χ2 test were used to compare continuous and categorical data as appropriate. Pearson's r correlation test was used to compute the relationship between initial analgesic administration time (minutes) and LOS (minutes) in the UC center from triage to disposition. A P value of less than .05 was considered statistically significant.
Pre- and postimplementation group characteristics
A total of 124 (pre: 61; post: 63) adult patients with VOEs in the UC center were included in the QI study. Demographics and clinical characteristics are reported in Table 1. No statistically significant differences in group characteristics were found between the pre- and postimplementation groups. Subject demographics and sickle genotypes were similar between the 2 groups, including age, gender, race, pain score in triage, type of first analgesic, disposition, and whether patients were on hydroxyurea therapy. However, patients aged between 18 and 27 years with VOEs had the highest UC center utilization rates.
All primary outcome measures demonstrated statistically significant improvements (Table 2).
- Aim 1: Mean time to first analgesic administration from triage decreased from 92 minutes (SD = 59) to 62 minutes (SD = 37) (P = .001).
- Aim 2: Patient satisfaction with acute pain management in the UC center increased from 23% to 68% who were satisfied before versus after implementation of the EBPSC (Fisher's exact test P = .002). A total of 26 preevaluation surveys and 25 postevaluation surveys were collected.
- Aim 3: Mean time to disposition from triage declined significantly from 283 minutes (SD = 169) to 256 minutes (SD = 97) (P = .010).
Initial analgesic administration time (minutes) was directly related to LOS (minutes) in the UC facility from triage to disposition: the briefer the time between triage and administration, the shorter the time until disposition (r = 0.223; total N = 124; P = .013) (Figure 2). Pain reassessment within 30 minutes after initial analgesic administration increased from 24.6% preintervention to 42.9% postintervention (P = .032). Patients' perception of receiving empathy increased from 23.1% preintervention to 64% postintervention (Fisher's exact test, P = .005) and shared decision making of acute pain management increased from 26.9% to 68%, respectively (Fisher's exact test, P = .005). Administration of the second dose of analgesic within 30 minutes after initial analgesic dose was unchanged (P = .375) as were 30-day readmission rate (pre: 31%; post: 19%; P = .120) and discharged home from the UC center (pre: 18%; post: 20.6%; P = .714) (Tables 3 and 4).
Data were collected through a pre- and postevaluation survey of UC providers (pre: 15/post: 21) and staff (pre: 14/post: 15) to assess attitudes and awareness of the EBPSC. The results demonstrated improved provider awareness of rapid pain management within 30 minutes from triage, from 80% preintervention to 95% postintervention (P = .254). Inadequate pain assessment tools were identified by 42% of 36 providers (pre: 15/post: 21) as the greatest barrier to rapid pain management. Staff awareness of guidelines that required rapid pain management within 30 minutes from triage increased from 28.6% preintervention to 100% postintervention (χ2 test, P = .000). Among the staff, 45% (n = 29; pre: 14/post: 15) identified lack of time or overcrowding in the UC center as the greatest barrier in the management of VOEs in patients with SCD. The percentage of staff who believed that SCD patients were drug-addicted declined from 57.1% preintervention to 33% postintervention (likelihood ratio χ2 = 6.723, df = 5, P = .242).
The implementation of EBPSC, including computerized triage order sets and education for the UC team, was associated with improvements in VOE pain management in patients with SCD during the implementation period. However, multiple confounding variables were identified and potentially affected project outcomes.
Overcrowding and unpredictable surges in volume in this UC setting, where the average daily census is 90, were challenging throughout the study. Both aspects had the potential to interfere with adoption among providers and staff. Another challenge was competing priority issues in this setting. In addition, this UC center prioritizes patients with trauma, stroke, heart disease, and sepsis. As a result, staff and providers cannot give priority to hemodynamically stable SCD patients: when UC center beds were occupied by patients with high-priority conditions, the waiting times for SCD patients lengthened significantly.
Resistance to change, lack of knowledge of EBP guidelines, nonacceptance of the evidence, and nonadherence by the UC team were barriers to be overcome. Some providers and staff did not grasp the importance of EBPSC for VOEs in patients with SCD. As a result, reinforcing communication channels was critical, as were anticipating and troubleshooting challenges during implementation. This QI study also involved establishing a new culture of quality within the work environment, requiring that team members follow quality guidelines themselves and consistently observe others taking quality-focused actions. Creating an environment in which quality-focused behavior is the norm can be a crucial first step in changing negative perceptions and stereotypes about the SCD population in the UC team. Furthermore, improving health care teams' knowledge of current EBP guidelines and rigorously evaluating outcomes allow the UC team to effectively meet population needs and understand the impact of practices that are grounded in strong evidence.
This report was a single-site study that was conducted with small, convenience samples. Imperfections in EMR could have led to inaccurate recordings. Other potential sources of bias included the limitations that are inherent to using a pre- versus postevaluation design and the Hawthorne effect from having providers and staff members collect UC center experience surveys in real time from patients in their care. The identified confounding variables might have masked an actual association. Furthermore, because this UC unit effectively functions as a sub-ED and thus differs from other UC settings, the effectiveness and sustainability of the EBP change of this project might be unsuitable for other ED or UC settings because patient flow patterns and severity of disease differ between sites.
Implications for future research
Implementing standard care is an effective means of translating strong evidence and experience into best practices to optimize care. However, health care teams and team members who harbor negative biases toward SCD patients might show low adherence to new EBPSC for acute VOE pain management. The barriers between EBPSC and day-to-day practice by health care team members deserve further research to improve care for acute SCD pain in multiple settings. The highest UC utilization group from this study echoes that in previous research,6 indicating that patients with SCD rely more heavily on acute care settings for SCD care posttransition from pediatric to adult care.33 These findings emphasize the need for more research to improve transition care in this population.
Health care teams should not ignore or underestimate SCD patients' pain. Implementing EBPSC and educating staff and providers about its function and need are crucial steps for improving the pain management of VOEs, creating a more positive patient experience, and routinizing the standard and quality care for the SCD population in the UC center. Even allowing for overcrowding in acute care settings, delays in acute SCD pain management can be overcome and the quality of care can be improved.
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