Intranasal Fentanyl and the Impact of an Emergency Department Pain Protocol on Hospital Admission Rates

Background: Sickle cell disease (SCD) is an inherited red cell disorder with many potentially devastating complications, including recurrent acute vaso-occlusive (VOC) pain episodes. VOC pain accounts for >75% of emergency department (ED) visits and a significant number of hospitalizations annually. Patients with SCD frequently cite ED care as an area with the greatest need for improvement, with considerable variation in the clinical management of acute pain in this vulnerable patient population.

Objective: To determine whether timely and appropriate implementation of an intranasal Fentanyl-based standardized SCD ED pain protocol correlates with improved clinical outcomes and decreased hospital admission rates for patients with SCD.

Design/Methods: We conducted a pre/post-intervention study to evaluate the impact of a standardized pain protocol in pediatric patients with SCD between ages 0 to 21 years old, presenting to an academic free-standing pediatric hospital in the Midwest for evaluation of uncomplicated VOC pain. A retrospective electronic medical record chart review (EMR) was performed between June 2015 and May 2018, and following protocol implementation in July 2018, a prospective analysis was performed from January to December 2019. Data collected included pain scores, analgesia selection, disposition (discharged/admitted), and length of inpatient stay (LOS). Categorical variables were summarized as percentages. Continuous variables were summarized as means and standard deviations. Due to multiple observations per subject, a Generalized Estimating Equations (GEE) model was used to test for differences between prior and post-intervention.

Results: Pre-intervention, 162 unique patients accounted for a total of 471 ED encounters, and post-intervention, 80 unique patients with 162 ED encounters for uncomplicated pain. The mean age at presentation was higher in the post-intervention cohort [pre vs. post 9.2 ± 5.9 years vs. 11.1 ± 5.5 years in the post-intervention group (p <0.0001)]. Sex was similar amongst the groups (p=0.2703), as was genotype (Hb SS pre vs. post: 66% vs. 65%, (p=0.8271). Time from ED check-in to the first analgesia dose (pre vs. post: 72.8 ± 53.4 minutes vs. 50.2 ± 29.6 minutes, p<0.0001) and time between physician order to first analgesia dose (pre vs. post 26.7 ± 23.4 minutes vs. 20.4 ± 17.7 minutes, p=0.0005) significantly decreased in the post-intervention cohort. The final pain score documented before ED discharge (pre vs. post: 5 (IQR1-7) vs. 6 (IQR 2-8), p=0.1451) was similar pre- vs. post-intervention. IV/IN analgesia was used initially in 69% of pre-intervention encounters and increased to 91% in the post-intervention encounters with IN Fentanyl being the preferred analgesic agent (61%). The average ED LOS was similar between the two cohorts (pre vs. post: 5.0 ± 1.8 hours vs. 5.0 ± 1.8 hours, p=0.7711) with a decreased frequency of admission (pre vs. post: 69% vs. 53.1%, p=0.0017) and decreased inpatient LOS (pre vs. post: 4.2 ± 4 days vs 3.6 ± 2.9 days, p=0.0019) in the post-intervention cohort.

Paired Analysis: Fifty-four subjects were reflected in both the pre-and post-cohorts and compared in a subanalysis of the last ED visit prior to intervention to the first ED visit post-intervention. Admission rates significantly decreased in the post-intervention cohort (pre vs. post: 70.4% vs. 50%, p=0.0116), and the median number of analgesia doses increased (pre vs. post: 2 (1-3) doses vs. 3 (2-4) doses). There was no difference in the average ED LOS or inpatient average LOS. The average timing between ED check-in and the first analgesia dose was significantly lower in the post-intervention cohort (pre vs. post: 82.8 ± 65.6 vs. 49.9 ± 29.8 minutes, p=0.0007).

Conclusion: The acute nature of many SCD complications, including VOC, makes the ED an everyday setting where management of this population occurs. Our study illustrated the significant impact a standardized treatment algorithm created with a multidisciplinary group of champions can have on time to the first dose of analgesia and outcomes such as hospitalization rates, suggesting improved pain management. Future work will be focused on understanding how these systems and clinical improvements translate to patient experience and patient-reported outcomes.