Reports From the Field

Using Quality Improvement Methods to Implement an Individualized Home Pain Management Plan for Children with Sickle Cell Disease

Journal of Clinical Outcomes Management. 2014 May;21(5)

 

The goal was that at least 85% of all eligible patients would receive the home plan intervention by November 2012 (population metric). We did not achieve 85% until February 2013 due to scheduling difficulties during that time period. By May of 2013, 88% ( n = 188) of all eligible patients in the population had received a home plan ( Figure 2 ). Of the 12 eligible patients who did not receive a HPMP, 6 were in the process of transitioning to an adult hematologist and were being seen for the last time in the pediatric SCD center, one patient needed to leave and didn’t have time to complete the intervention, one patient arrived in acute pain, one patient had other treatment issues to discuss and asked to postpone the pain management discussion, and 3 patients did not have an obvious reason but the provider likely did not have time to implement or forgot to implement the HPMP protocol.
From January 2012 to May 2013, the percentage of patients who were seen in the ED for uncomplicated SCD pain decreased from 6.9% to 1.1%, an 84% decrease ( Figure 3 ). With respect to return visits to the ED, 1.3% of eligible patients ( n = 2) returned to the ED for treatment of uncomplicated SCD pain within a 30-day period of a prior visit for uncomplicated SCD pain.

DISCUSSION

Using quality improvement methods, an individualized home pain management intervention was incorporated successfully into the daily workflow of a busy outpatient SCD clinic. The QI team provided critical guidance, organization, and resources for refining the HPMP intervention and implementing it into a very busy outpatient clinical setting. QI methods such as the PDSAs, FMEA, and process maps allowed us to continuously improve the intervention and develop an effective implementation process. As a result, we were able to reach our goal of ensuring that 100% of eligible patients received a HPMP during their clinic visit.

Several studies have shown cognitive-behavioral therapies, such as relaxation, imagery, and self-hypnosis, to improve outcomes in children and adults with SCD [7–10]. We believe that having psychology providers on our team who could train families in nonpharmacological strategies was critical to the project’s success. Most SCD patients are taught to increase fluid intake and use warm compresses, but few are trained in adjunctive nonpharmacologic strategies while awaiting the effects of oral analgesics. Thus, our multidisciplinary protocol is innovative; future studies may show it to to be more effective than interventions using pharmacologic or nonpharmacologic strategies alone.

Implementing a comprehensive home pain management intervention in a very busy clinical setting was challenging; it required a substantial coordination and communication among the clinical team. Although each member of the team had a well-defined role, we found that our nurse care managers were the drivers of the process during the clinic visit. They ensured the documentation of the HPMP and reconciliation of medications were completed in the EMR, that prescriptions for analgesics were written and educated families to execute the HPMP.

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