P1440: assessing adherence to emergency department protocols for sickle cell disease: implications for quality of care

Topic: 26. Sickle cell disease Background: Patients with Sickle Cell Disease (SCD) experience frequent vaso-occlusive crises (VOC) leading to significant morbidity and mortality. Emergency department (ED) visits for VOCs are a common cause of ED presentation and hospital admission. Standardized protocols for acute care in SCD are essential for prompt and effective treatment may result in reduced length of hospitalization. In 2019, a new protocol for the ED diagnosis and management was introduced in our hospital, but local adherence has not been evaluated. Aims: This study aimed to assess the quality of care for patients with sickle cell disease (SCD) in the emergency department (ED) and to revise existing protocols to improve the care provided. Methods: The study was a single-center observational cohort study with both retrospectively and prospectively collected patient data. The study population consisted of all patients aged 18 years and older with SCD who visited the ED from March 1st, 2021 till October 12th, 2022 with a painful VOC requiring hospital admission. From December 1st 2022 till January 23rd 2023, similar patient data was collected prospectively after protocol revisions based on the data from the first sample. The primary outcome measure was protocol adherence. Other outcomes included length of stay (LOS) in the ED, total hospital LOS, acceptable pain level registered in ED (APLED) and SCD-related complications. Results: Out of 324 ED visits, 167 VOC presentations (96 unique patients) were included. Retrospective analysis showed that the care provided in the ED was suboptimal, with low adherence to both pain and supportive care protocols. Total protocol adherence for retrospective analysis was 0.0% (N=0). In only 34% (N = 56) of all presentations, opioids were administered within thirty minutes of arrival, with a median of 33 min (IQR 22 – 49) for all analgesics and 32 min for intravenous opioids. The median cumulative morphine dose was 7.5 mg (IQR 5.0 – 13). Current pain treatment protocol indicates that morphine can be repeated till a maximum of 50 mg, which shows that the overall duration of morphine treatment takes relatively long with a relatively low cumulative dose. The time between morphine gifts correlated significantly with LOS in ED (p = 0.003). After analysis of this first sample, protocol revisions included a shorter time interval between opioid dose and higher opioid dose for titration. Moreover, an analgesic bundle was instituted upon arrival instead of step-up medication. After the implementation of the revised protocol, total adherence slightly increased to 4.3%. LOS in ED, total hospital LOS and registered APLED did not differ significantly from the retrospective cohort (p = 0.786, p = 0.885 and p = 0.414, respectively). Time to first analgesic administration showed significant improvement (p= 0.036). The median length of stay in the ED was 3 hours and 37 minutes. Summary/Conclusion: This study found that the care provided in the ED to patients with SCD was suboptimal, with low adherence to both pain and supportive care protocols. After protocol revisions, total protocol adherence improved significantly. The study highlights the importance of implementing and adhering to established protocols for the care of SCD patients to ensure optimal patient care and avoid prolonged hospital stays. The findings of this study could be useful for other hospitals and centers that provide care for SCD patients. More VOC presentations should be followed and analysed prospectively to calculate results on more weighted outcomes for adherence, LOS and complications. Keywords: Sickle cell disease, Sickle cell