Adult Emergency Department Patients with Sickle Cell Pain Crisis: A Learning Collaborative Model to Improve Analgesic Management

Abstract

Objectives: The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative.Methods: A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data.Results: A total of 155 patients met study criteria (median age = 32 years, IQR = 24-40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes . Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean ± SD = 4.19 ± 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean ± SD = 5.77 ± 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43).

Hospital Readmissions in Patients With Inflammatory Bowel Disease

“…Several studies in the surgical literature (14,15) have demonstrated the potential for "fast-tracking" postoperative patients with some success. Additionally, in patients with sickle-cell disease, a lot of research in emergency rooms and outpatient and inpatient settings has been focused on developing the best collaborative approach to minimize resource utilization and improve pain control (16)(17)(18). Another significant issue in IBD patients is nutrition.…”

A Survey of the Pain Management of Acute Painful Crisis among Patients with Sickle Cell Disease at Two Centres in Jamaica

“…Three studies in the United States of America (USA): Benjamin et al (2000), Tanabe et al (2007) and Tanabe et al (2010) reported achieving initiation within 20 minutes, 90 minutes and 74 minutes, respectively (11,14,15). The results of this survey showed mean times to initiation of analgesic therapy of 38 minutes and 111 minutes at SCU and A&E, respectively.…”

“…The results of this survey showed mean times to initiation of analgesic therapy of 38 minutes and 111 minutes at SCU and A&E, respectively. Possible reasons for delays in the initiation of therapy proffered by Tanabe et al (14,15) include over-crowding and "under-triage" or the assigning of a lower priority level. Interestingly, negative attitudes toward "frequent attenders" were not cited as a cause for delay by Tanabe et al (14,15).…”

“…Possible reasons for delays in the initiation of therapy proffered by Tanabe et al (14,15) include over-crowding and "under-triage" or the assigning of a lower priority level. Interestingly, negative attitudes toward "frequent attenders" were not cited as a cause for delay by Tanabe et al (14,15). It could be argued, however, that "under-triage" was the manifestation of the negative perception of SCD patients that abound in the literature (16−19) and can affect perceptions and assessment of priority.…”

Management of Pain in the Emergency Department

“…The agent does seem to be gaining popularity for use in the ED, for reasons that are both evidence based and anecdotal. The evidence basis for hydromorphone use in the ED is long standing and broad, for indications ranging from renal colic [189] to sickle cell crisis [190]. As for the anecdotal reasons for hydromorphone's growing popularity, some physicians (including this author) have found that hydromorphone use can be a route around inappropriately overcautious nurses who (despite requests to the contrary) split 0.1 mg/kg morphine orders into nearhomeopathic doses administered over 15-30 minutes "for safety. "…”