A QI Project to Improve Pain Management in Sickle Cell Vaso-Occlusive CrisisDana LeBlanc, MD, Renee Gardner, MD, Maria Velez, MD, Cori Morrison, MDPediatric Hematology/Oncology and Hematopoietic Stem Cell Transplant LSUHSC/Children’s Hospital of New Orleans

Background• Sickle Cell Disease (SCD) affects 70,000 -100,000 Americans

• 2,000 infants are born with SCD each year

• Pain due to vaso-occlusive crises (VOC) is a leading cause of hospital admission and healthcare cost in pediatric patients with SCD

• National Hospital Ambulatory Medical Care Survey• 1999-2007: ~200,000 ED visits/yr for SCD• 78% of visits were for pain • 17% of patients 0-19 yrs of age

Background• Lack of consistent healthcare provider education regarding

management of these patients often results in delayed or inadequate analgesic administration• Prolongs hospital stays• Leads to patient distrust and dissatisfaction with the medical

team

Pathogenesis• Nucleotide substitution in the beta globin gene (glutamic

acid to valine) allows hemoglobin S polymerize in deoxygenated states

Treatment of VOC• IV hydration• Parenteral opioid administration• Morphine or Dilaudid• Patient controlled analgesia (PCA) or on demand boluses

• Adjuvant therapies• NSAIDs• Tricyclic antidepressants

Objectives• To evaluate and improve physician education, attitudes and

comfort level regarding management of SCD VOC

• To improve the timeliness of achieving adequate pain control during a VOC

• To reduce hospital stay duration, reduce readmission rates, and improve patient satisfaction with VOC management

• Ultimately, to improve the overall quality of life of our sickle cell patients

Study Design

• 3 parts:• Physician Education and Surveys• Patient Surveys• Inpatient Data Analysis

Physician Education & Surveys• Educational modules• Grand rounds presentation• Interactive pain management workshop as part of the intern

lecture series• Video recorded “refresher” prior to starting Hematology service

month• Materials• Preprinted VOC order forms• Pocket cards with pain management guidelines

• Pre and post education surveys• Assess resident knowledge and understanding of VOC

management• Assess resident attitudes regarding SCD patients and VOC

Preprinted Orders for VOC

Study Tools

Patient Surveys• Will survey patients both prior to and after initiation of

physician education

• Will assess: • Patient satisfaction with medical care received

• Confidence in the medical staff• Patient perception of pain management

• Preferred medications• Promptness of administration• Physician attitudes

• Patients to be surveyed at routine clinic visits

Inpatient Data Analysis• Retrospective chart review of SCD patients admitted for pain

crises • Data to be collected:

• Number of hospital days• Time until optimal pain control is achieved• Method of narcotic administration and maximum dose required• Adjuvant therapies • Readmission rates

• Pre and post survey data will be analyzed

Anticipated Results

More consistent pain management• Improved physician education• Standardized pain management orders• Pain management guidelines

Faster resolution of VOC• Adequate pain control achieved more quickly• Shorter hospital stays with fewer readmissions

Greater patient satisfaction• Improved trust and confidence in the medical staff• Less time spent hospitalized• Improved quality of life

Questions?