Background: Sickle cell vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visit and admission in children with this condition. Intranasal (IN) fentanyl has been used increasingly for pain treatment in the emergency department (ED), including for patient with sickle cell disease (SCD).

Objectives: We aim to evaluate whether the use of a new pain management pathway using IN fentanyl from triage as first line therapy for patient with SCD in VOC will lead to improved care of SCD, translated by a decrease in time to first opiate dose, aiming to meet quality of care indicators. We also aim to prospectively evaluate patient and parent satisfaction with the use of IN Fentanyl.

Methods: Retrospective chart review of patients with SCD who presented to the ED with VOC, in the period pre (Jan - June 2014) and post (Oct - June 2016) implementation of the protocol. Patients in pre received oral or intravenous (IV) opiates as per previous management pathway. Patients in post received IN fentanyl if their pain was moderate-to-severe. Time to first opiate was evaluated pre and post implementation. Patient and parent satisfaction questionnaires were filled prospectively if patient presented during research nurse working hours, and median scores were calculated.

Results: Over the two periods, a total of 107 ED patients (56 pre, 51 post) were included respectively, and 14/51 patients filled out the satisfaction questionnaire. There was a significant difference of -45.8 min (95% CI -61.1, -31.9) in the opiate administration time, now meeting quality of care indicators. There was a significant increase of 45.7% (95% CI 29.0, 59.0) in the use of pain scales at triage evaluation. There was an increase in the number of patient treated with a non-IV opiate as 1^st opiate dose: a difference of 43.8% (95% CI 26.7, 57.4). There was no difference in the number of patients without IV treatment: a difference of 15.8 (95% CI -1.4, 32.1). There was no difference in the hospitalization rates: a difference of 12.6 (95% CI -6.2, 30.1. Patient and parent satisfaction with IN treatment was 3.5/5 and 2/5 for the 14 patients evaluated prospectively.

Conclusion: This study validates the use of our protocol using IN fentanyl for the treatment of VOC in the ED by significantly reducing the time to 1^st opiate dose. However, our protocol did not decrease the number of IVs.