Implementation of a CPG to manage acute sickle cell pain in the ED improves the ability to deliver timely, effective analgesia to this patient population. Establishing and monitoring internal benchmarks provides a means for ongoing evaluation of the pre-established goals for patient care.

Over twelve thousand children are diagnosed each year with cancer, and approximately 2200 children die each year from the disease. A percentage of these patients experiences escalating and intractable distress with symptoms that include pain, dyspnea, and agitation. These symptoms may continue for hours to days. Intractable symptoms of pain, agitation, and dyspnea can be very distressing to the patient, family, and staff and often a challenge for the physicians and nursing staff to treat. To meet this challenge, The Dana-Farber Cancer Institute/Children's Hospital Cancer Care Program has made it a priority to create a process of care that includes identifying barriers to care and the development of an end-of-life (EOL) rapid response model that includes guidelines and physician-templated orders for rapid escalation of opioids. The goal of this quality-improvement initiative was to develop a model of care that would enable the caregivers to provide effective comfort care to any patient experiencing symptoms of rapid escalation of pain, dyspnea, and agitation. A model of care was created to overcome barriers to care. The model includes role clarification, "Guidelines for the Management of Escalating Pain/Dyspnea/Agitation at the End of Life," and "Rapid Titration-Templated Physician Orders." Staff feedback was solicited relative to the content, format, and usability of the guidelines and templated orders. The physician and nursing staff reported that they found the templated orders and guidelines very helpful and effective and suggested only a few edits. A retrospective chart review is currently under way. The purpose of this chart review is to systematically document and compare the record of management of rapidly escalating symptoms of pain and/or dyspnea and/or agitation prior to and after instituting the EOL Rapid Response Model of Care. Care of the EOL patient experiencing symptoms of pain, dyspnea, and agitation is challenging. The EOL Rapid Response Model of Care outlines a process of care and provides recommendations and templated physician orders for rapid titration of opioids.

More than 48,000 newly diagnosed cancer patients can expect to have some adverse events related to their care each year. Historically, 20% of these adverse events have been medication related, and two thirds have been thought to be preventable. Since the majority of these errors occurred during the order writing process, the prioritized changes made at the joint pediatric program for Children's Hospital, Boston, and Dana-Farber Cancer Institute have been the initiation of templated orders and the development of a computerized order entry system. The goal of this initiative was to decrease errors related to chemotherapy administration by creating legible, complete, clearly defined order sets, and at the same time, to make order writing and reviewing more efficient. Chemotherapy templates were created using a consistent format and a rigorous multidisciplinary review process. Each order set includes the following: identification of the patient and cycle of chemotherapy to be given, criteria necessary to receive chemotherapy, chemotherapy orders with modifications if appropriate, and supportive care orders. Templated order sets have reduced the duplication of work efforts by significantly reducing the number of changes made during the order verification process; orders are more complete, and standardization has occurred.