Addressing time delays in opioid administration for vaso-occlusive pain episodes in sickle cell disease: A Quality Improvement initiative
Ramya Ramakrishnan, Jessica Justus Kurian, Ryan Kiser, Suraj Pratap, Emily BralyAbstract
Background
Vaso-occlusive pain episodes (VOE) are a common cause of emergency department (ED) utilization and subsequent hospital admission in individuals with sickle cell disease (SCD). Guidelines emphasize timely opioid administration and frequent reassessment with dose titration to achieve adequate pain control. When analgesics are delayed, pain control is challenging, often necessitating higher cumulative opioid doses and subsequently longer hospital stay. Despite established recommendations, real-world workflows can introduce significant delays in opioid delivery, particularly during the transition from ED to inpatient unit. Various strategies have been explored to mitigate these gaps including employment of patient-controlled analgesia (PCA) from the ED, instead of inpatient, highlighting a practical approach to maintaining continuous pain control during handoff periods. Our Quality Improvement (QI) initiative aims to identify and address challenges in the timely administration of opioid medications for VOE at the Oklahoma Children’s Hospital (OCH).
Methods
The QI initiative employed Plan–Do–Study–Act (PDSA) cycles to guide testing of the interventions. Institutional Board Review approval was obtained and a retrospective electronic medical record (EMR) review of all patients < 21 years of age with SCD, admitted to the pediatric inpatient unit from the ED at OCH for management of VOE, from January 2025 to December 2025 was conducted. Patients were identified using ICD-10 codes for VOE. Patients who did not require scheduled opioids for management of VOE were excluded. Data collected included age at admission, sex, SCD genotype and type of opioid medication used on admission. The following time points were noted for each admission – ED arrival, first opioid and last opioid administration respectively in the ED, time of admission and first opioid administration in the inpatient unit. Time of PCA pump initiation, if required for pain control was noted. The average of each time point for all admissions was then calculated.
Results
Eighty-one inpatient admissions from the OCH ED met our inclusion criteria. Of these, 65% admissions required PCA initiation. Demographic and clinical characteristics of patients included in our study are depicted in table 1. The mean time interval from ED arrival to first opioid administration was 54 minutes. Mean time interval from the receipt of last opioid in the ED to the first opioid administration on admission was 217 minutes, timeline is depicted in figure 1. To decrease the time interval between last opioid administration in the ED and the first opioid on the inpatient unit, an order set was created within the EMR to have four as needed (PRN) opioid doses available every 30 minutes to administer, prior to initiation of any pain regimen or PCA on admission. The order set was designed to ensure discontinuation of PRN opioids once inpatient opioids were ordered. Data will be collected and reanalyzed over two PDSA cycles, consisting of 3 months each.
Conclusions
The delay in transition of care from ED to inpatient unit and PCA pump configuration on admission, likely impede timely opioid administration. It is thus imperative to identify and address time gaps in opioid administration for VOE in patients with SCD, to achieve adequate pain control and improve patient outcomes.