Evaluation of a Pediatric Emergency Department Clinical Pathway for Vaso-Occlusive Pain: Evidence, Adherence, and Clinical and Operational Outcomes

Abstract

Introduction: Sickle cell disease (SCD) is associated with recurrent vaso-occlusive pain (VOP) which is the most common reason pediatric patients with SCD seek emergency department (ED) care. National guidelines recommend rapid opioid administration and continued reassessment and redosing during VOP management; however, considerable variability persists in pharmacologic strategies, medication timing intervals, and adherence to evidence-based care processes. This dissertation examined variability in pediatric ED management of VOP through evaluation of existing evidence, clinical pathway adherence, and outcomes associated with implementation of a VOP clinical pathway.Methods: This dissertation consists of three complementary studies. Chapter 2 used a scoping review to map existing literature examining pharmacologic selection and timing goals in relation to clinical and operational outcomes among pediatric patients presenting to the ED with VOP. Chapter 3 described a retrospective variance analysis to evaluate whether adherence to sequential clinical pathway timing recommendations was associated with faster pain improvement among pediatric patients receiving treatment for VOP following the implementation of the clinical pathway. Chapter 4 described a retrospective pre- and post-implementation study design to evaluate differences in ED outcomes associated with implementation of a VOP clinical pathway, including time to first opioid administration, ED length of stay among discharged patients, and odds of discharge. Results: The scoping review identified heterogeneity in pharmacologic management strategies, medication timing definitions, and operational and clinical outcome measures across studies evaluating pediatric VOP management in the ED. Findings from the variance analysis demonstrated that higher levels of adherence to sequential opioid timing goals were associated with a faster decrease of at least 2 points in patient self-reported pain scores. Implementation of the VOP clinical pathway was associated with improvements in time to first opioid administration and decreased length of stay for patients discharged from the ED. Conclusion: These studies provide insight into evidence and practice variability, clinical pathway adherence, and operational and clinical outcomes associated with use of a clinical pathway for pediatric ED management of VOP. Findings from this dissertation support the use of clinical pathways for improving the consistency and timeliness of pain management for pediatric patients with SCD and identify opportunities for future research examining approaches to reduce variability in VOP care.