Evaluation of Pain Management in Sickle Cell Patients Through the Use of Pain-Control Algorithms and Provider Education

Brittany Carlson, PharmD
PGY1 Pharmacy Practice Resident
Jackson Memorial Hospital—Jackson Health System
Miami, FL

Sickle cell disease is a group of inherited red blood cell disorders in which hemoglobin forms into an unusually sickled shape, causing the natural red blood cell to shorten its life span and lose its flexibility.¹ Sickle cell patients often have frequent hospital readmissions throughout their lives, with one of the precipitating factors being vaso-occlusive crisis (VOC). VOC occurs when the sickled cells occlude the vasculature, leading to hypoxia in the tissue following the occlusion.¹ Tissue hypoxia is known to cause an intense amount of pain and is the main cause of sickle cell patients’ admission to the hospital. Optimal treatment for VOC is rapid administration of intravenous (IV) opioids followed by physician-driven pain management.² Inconsistencies in the maintenance of patients experiencing VOC have been observed at Jackson Memorial Hospital, inconsistencies likely due to the subjective nature of a patient’s pain level and provider preference. The variability in the treatment of this condition has led to an increase in hospital length of stay, variable prescribing of pain regimens, and a decline in patient satisfaction at Jackson Memorial Hospital.

Because of the concerns addressed above, an inpatient sickle cell pain management algorithm was formulated and implemented at Jackson. This pharmacy-driven protocol involved a multidisciplinary team of physicians, nurses, nurse practitioners, and a pharmacy resident. The inpatient sickle cell pain management algorithm outlines preferred opioid regimens, options for nonopioid adjunctive therapies, guidance to transition from IV to oral opioids, and suggested opioid regimens upon discharge. This algorithm was created by a team of pharmacists using the current literature on VOC and guidelines for treating it. In conjunction with the algorithm implementation, a power plan was released in the Cerner electronic medical record database at the same time. A power plan is an order set that aids physicians when they are ordering several medications for a patient subset. The sickle cell power plan provides an easy way to order medications that a sickle cell patient may need and follows the algorithm for initial pain management. The power plan was implemented as a tool for physicians, though its use was not mandatory. The purpose of this project was to standardize the approach to pain management for admitted sickle cell patients who were experiencing a VOC.

The pharmacy resident completed a retrospective two-phase study that evaluated VOC pain management before and after implementation of the sickle cell pain management algorithm. Phase 1 was conducted retrospectively to evaluate data from July 2018 to September 2018. Data were collected in order to establish a baseline for prescribing patterns, morphine equivalence trends, and the effect of prescribing trends on length of stay. Phase 2 was conducted from January 2019 to March 2019 following implementation of the algorithm. Patients admitted for VOC were identified via an International Classification of Diseases-10 code. As part of the implemented protocol, each patient’s medication profile was evaluated daily by a pharmacy resident to consider appropriateness of the pain regimen and identify potential areas of deescalation of therapy. The goal of the medication review was to aid the providers in adhering to the sickle cell pain management algorithm. If the resident found room for improvement, the patient’s primary medical team was contacted in order to optimize therapy.

The primary outcome measured was hospital length of stay. Secondary outcomes were time to transition from IV to oral opioids, use of concomitant central nervous system (CNS) depressant medications, the appropriateness of hydroxyurea use, overall power plan use, and 30-day readmission rates related to VOC.

After implementing the sickle cell inpatient power plan and sickle cell pain management algorithm, data from 114 patients (phase 1, n = 57; phase 2, n = 57) showed a trend toward a decreased length of stay, with an overall reduction of 0.7 days (p= .25), though the results were not statistically significant. VOC-related hospital readmission rates at 30 days did decrease significantly from 41% pre-algorithm to 26% post-algorithm (p= .02). The sickle cell power plan was used in 63% of cases. The most significant change seen with the implementation of the sickle cell algorithm was a decrease in the concomitant use of IV diphenhydramine. Preimplementation of the algorithm, 84% of patients received at least one dose of IV diphenhydramine versus 68% of patients postimplementation (p= .08). Additionally, 63% of patients were receiving more than five doses of IV diphenhydramine preimplementation, whereas only 16% received that many in the postimplementation group (p= .002). The reduction of IV diphenhydramine use was targeted in order to mitigate potentially harmful adverse CNS effects that may arise because of concomitant CNS depressant usage.

After implementation of the sickle cell pain management algorithm, a nonstatistically significant decrease in length of stay and statistically significant 30-day readmission rate for sickle cell patients admitted for VOC were found. The success of the implemented algorithm and order set was found to be dependent on prescriber participation and education on the mechanics of using the power plan and algorithm. Deescalating therapy was most successful when an interdisciplinary approach was used. On the basis of these results, a sickle cell task force that meets weekly to optimize the care of these patients has been established at Jackson Memorial Hospital.

One limitation of this study was that use of the sickle cell power plan was optional. As more providers choose to use the power plan, a more standardized approach to treating VOC will develop. Another limitation was the number of patients who were frequently readmitted to the hospital. These patients were inpatients several times throughout the course of the study and had comorbidities outside of sickle cell disease that could have contributed to their longer length of stay and therefore confounded the study results.

It is expected that with further education of providers and greater use of the sickle cell power plan and algorithm over time, a more significant decrease in hospital length of stay will be seen. The newly implemented sickle cell task force continues to aid in the optimization of care for these patients at Jackson Memorial Hospital.

References

1. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. (2002). The Management of Sickle Cell Disease (NIH Publication No. 02-2117). Retrieved from https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/management-sickle-cell-disease
2. Uwaezuoke SN, Ayuk AC, Ndu IK, et al. Vaso-occlusive crisis in sickle cell disease: current paradigm on pain management. J Pain Res. 2018;11:3141-3150.