Standardized order sets reduce medication errors and create efficiency for physicians, nurses, and pharmacists.1 A less recognized benefit may be that standardized orders promote equity in care and may help to mitigate disparities that occur along racial and ethnic lines. Patients admitted with an acute pain crisis secondary to sickle cell disease (SCD) are often suspected of drug-seeking behavior and may be treated in a cursory manner because they are “frequent flyers” on the medical service. In view of these factors, this patient group may benefit more than others from a standardized treatment protocol. Over the past year, hospitalists and other clinicians at Novant Health in Charlotte, N.C., have composed an admission order set for SCD pain crisis in an effort to improve care for this underserved group.
Novant Health
Novant Health is a multi-hospital, non-profit system serving 3.5 million people from Virginia to South Carolina. Presbyterian Hospital, a 531-bed facility in Charlotte, N.C., is the flagship hospital for Novant’s Southern Piedmont Region (SPR). Presbyterian Inpatient Care Specialists (PICS) is a 44-provider group that offers hospitalist services for adult patients at Presbyterian Hospital, two community hospitals in Matthews and Huntersville, and Presbyterian Orthopedic Hospital.2 In 2005, 180 adult patients were discharged from the Novant-SPR hospitals with a principal diagnosis of SCD, and most of these patients were managed by PICS. This cohort of 180 patients accounted for more than 600 hospitalizations for SCD-related illness at the Novant-SPR facilities in 2005.
Process and Procedure
Standardized order sets have been in widespread use at the Novant-SPR facilities for a number of years. The process of order set development begins with patient needs as perceived by medical staff. Once a physician has drafted an order set, the draft is reviewed by the Order Set Subcommittee, a multidisciplinary team chaired by Susan Smith, RPh, PharmD, with nurses, physicians, and other support staff represented as needed. Once the subcommittee has approved the draft, it goes to the Pharmacy and Therapeutics Committee for final approval. In this fashion, more than 600 order sets have been developed and made available on the hospital’s intranet. The PICS team has helped to develop a number of disease management order sets and protocols, including the general medical admission orders. In addition, PICS has assisted in developing disease-specific orders for community-acquired pneumonia (CAP), CVA/TIA, and other common diseases admitted by the hospitalist service.
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In the case of the adult SCD pain crisis order set, Stephen Wallenhaupt, MD, chief medical officer for Novant Health, recalls, “We recognize that SCD patients have unique needs in terms of pain management and that a standardized order set which incorporates aggressive pain management options is the best way to meet their needs.”
Fran Davis, RPh, PharmD, researched the pertinent literature and consulted the anesthesiologists on staff in an effort to tailor the pain management options for SCD patients. Using the recommendations of these specialists, the order set reflects the consensus that patients with a severe SCD pain crisis require parenteral opiate analgesia on admission.3
Because many patients admitted by PICS can be categorized as having severe pain, the order set contains choices for patient-controlled analgesia (PCA), in keeping with the recommendation for opiate administration at a fixed interval rather than on an as-needed basis.4 And because many hospitalists may not be familiar with ordering PCA, the SCD orders specify the dose ranges, as well as the lockout interval for morphine and hydromorphone PCA. With PCA options readily available, hospitalists need not delay therapy while awaiting a consultation from the pain management service. For all patients receiving opiates, the order set contains an automatic order for naloxone for respiratory depression manifested by a respiratory rate less than nine.