Intranasal fentanyl and impact of an emergency department pain protocol for sickle cell disease on hospitalization rates

Sickle cell disease (SCD) is an inherited red blood cell disorder with significant complications, including vaso-occlusive crisis (VOC), the most common cause of emergency department (ED) visits and hospitalizations. Pain in children with SCD is often underestimated. We evaluated the impact of a standardized institutional nurse-initiated ED SCD pain protocol, using intranasal (IN) fentanyl (INF) as the initial agent, on hospital admission rates. We conducted a preintervention/postintervention study of patients with SCD (aged 0-21 years) presenting to a quaternary pediatric ED for uncomplicated VOC pain from June 2015 to December 2019. Overall, 162 patients accounted for 471 ED visits in the preintervention period and 80 patients accounted for 162 visits in the postintervention period. After intervention, hospitalization rates (P = .0017) and inpatient length of stay (P = .0019) decreased, but median pain scores at presentation (P = .0047) and discharge (P = .1451) remained comparable. The time to initial analgesia dose significantly improved in the postintervention (P< .0001), along with the time from physician order to initial analgesia administration (P = .0005). IV and IN analgesia use rose significantly in the postintervention (odds ratio, 4.7; P< .0001), with INF being the preferred analgesic agent (61%) and a corresponding reduction in oral analgesic use (P< .0001). In an ad hoc sustainability analysis, INF use remained high and time to first dose was sustained. Implementing a standardized ED SCD pain protocol improved timeliness and consistency in analgesia administration and decreased overall hospitalization rates. This study also highlights the role of INF as an effective initial analgesic within standardized ED protocols for pediatric VOC.