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A Multiyear Cross-sectional Study of Guideline Adherence for the Timeliness of Opioid Administration in Children With
David C Brousseau1, Elizabeth R Alpern2, James M Chamberlain3
1Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
Insights
Guideline adherence for sickle cell disease (SCD) pain crises is poor, with only 48% of patients receiving their first opioid on time and 15% receiving subsequent doses promptly. Quality improvement efforts are needed to enhance timely SCD pain management in emergency departments.
Area of Science:
- Emergency Medicine
- Pediatrics
- Hematology
Background:
- Sickle cell disease (SCD) pain crises require timely opioid administration per National Heart, Lung, and Blood Institute guidelines.
- Multisite studies evaluating adherence to these guidelines are lacking.
Purpose of the Study:
- To assess adherence to evidence-based guidelines for timely opioid administration in children experiencing SCD pain crises across a multicenter network.
- To identify variations in adherence among different emergency departments (EDs) and over time.
Main Methods:
- A multiyear, cross-sectional analysis of 4,578 SCD pain crisis visits to 7 EDs within the Pediatric Emergency Care Applied Research Network (PECARN) from 2016-2018.
- Visits for uncomplicated SCD crisis receiving opioids were included; data extracted from electronic health records.
- Guideline adherence defined by time to first opioid (≤1 hour) and time between first and second opioid (≤30 minutes).
Main Results:
- Median time to first opioid was 62 minutes; median time between first and second opioid was 60 minutes.
- Overall guideline adherence for the first opioid was 48%; for the second opioid, it was 15%.
- Significant site variation in adherence was observed (first opioid: 22%-70%; second opioid: 2%-36%), with no change over calendar years.
Conclusions:
- Adherence to timely opioid administration guidelines for SCD pain crises is suboptimal in pediatric EDs.
- Significant disparities in care exist across different healthcare sites.
- Dissemination and implementation research and quality improvement initiatives are crucial to improve pain management for SCD patients.
Study Objective:
The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network.
Methods:
We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5°C (101.3°F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years.
Results:
A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P<.001). There was no change in timeliness to first dose or time between doses across years (P>.05 for both).
Conclusion:
Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.
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