Operational Factors Associated With National Guideline Adherence to Vaso-Occlusive Crisis Management in the Emergency Department

Objectives The National Heart, Lung, and Blood Institute guidelines for sickle cell disease (SCD) vaso-occlusive crisis (VOC) management recommend emergency departments (EDs) rapidly assess pain and administer pain medication following an individual's arrival. An ED's experience treating SCD along with co-occurring operational factors may affect guideline adherence. We investigated the effect of operational factors on VOC guideline adherence within a large New Jersey health system. Methods Electronic health record data between January 2022 and September 2025 were analyzed. Outcomes: rate of guideline-concordance, time-to-first and time-to-second pain medication administration. Adherence was defined as first dose ≤30 minutes after triage and second dose ≤ 30 minutes after first. Predictors: SCD patient volume, ED volume, shift, and emergency severity index (ESI) score. Descriptive and mixed-effects regression analyses were conducted. Results There were 7160 ED visits by 1401 patients. 14.2% of encounters were adherent for first pain medication, and 52.6% for second. SCD volume, ED volume, shift, and ESI score were associated with guideline-concordant encounter rates, but not site-level decreased average times. Shift timing was the only exposure significantly associated with mean times to both first and second pain medication administration. Individuals arriving during the evening shift received their first pain medication 15.93 minutes later (95% CI: 2.43 to 29.37) and their second pain medication 10.92 minutes later (95% CI: 4.01 to 17.83) than those arriving during the night shift. Conclusion Several operational factors were associated with the likelihood of guideline-concordant encounters; whereas, only shift timing influenced mean times to pain medication administration, highlighting a distinction between guideline concordance and overall timeliness.