Hospitalist Management of Vaso-Occlusive Pain Crisis in Patients With Sickle Cell Disease Using a Pathway of Care

Liles, E. Allen; Kirsch, John A. W.; Gilchrist, Michael J.; Adem, Mukhtar

doi:10.3810/hp.2014.04.1105

Cited by 8 publications

(9 citation statements)

References 30 publications

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“…This argument is further supported by results obtained by Jayaram et al, 13 who observed significantly improved ordering of IS, but no effect on ACS incidence following implementation of a CPW that did not mandate IS use. The lack of a significant decrease in the percentage of patients transfused PRBCs is consistent with results obtained by Liles et al, 21 but contrasts with results obtained by Jayaram et al, 13 possibly because of either variability in CPW design or higher disease severity in the post-CPW implementation group.…”

Section: Discussionsupporting

confidence: 88%

“…Results from previous CPW studies for vaso-occlusive pain also support the notion that readmission risk among patients with SCD depends on access to outpatient health care. The CPWs developed and studied by Liles et al 21 and Co et al, 9 which did not incorporate interventions to improve discharge planning, did not observe a significant effect on readmission rate, whereas the CPW of Frei-Jones et al, 22 which specifically addressed discharge planning, observed a significant reduction in 30-day readmission rate. Explanations for the CPW's lack of effect on hospital LOS include higher disease severity in the post-CPW implementation study group and the absence of interventions available for vaso-occlusive pain management that have been shown to independently reduce hospital LOS.…”

Section: Discussionmentioning

confidence: 97%

“…Difficulty in comparing vaso-occlusive pain episode severity between study groups may explain the variable results of CPWs on hospital LOS described in the literature. For instance, Co et al 9 and Jayaram et al 13 reported a longer hospital LOS after CPW implementation, whereas Liles et al 21 reported a significant reduction in hospital LOS post-CPW implementation. In this study, we observed trends toward increased incidence of ACS and increased percentage of patients transfused PRBCs in the post-CPW implementation study group, which may also suggest that the post-CPW group had more severe disease.…”

Section: Discussionmentioning

confidence: 99%

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Clinical Pathway for Vaso-Occlusive Pain Reduces Hospital Admissions

et al. 2021

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Background: Vaso-occlusive pain leads to high acute care utilization among patients with sickle cell disease (SCD). Data suggest that clinical pathways (CPWs) reduce variation in the management of vaso-occlusive pain and improve clinical outcomes. Methods: We implemented and evaluated a CPW for vaso-occlusive pain at our institution using a before and after study design. The primary objective was to decrease acute care utilization among patients with SCD, which was assessed by the primary outcome measures of hospital length of stay (LOS), 30-day readmission rate, and total hospitalizations annually per patient. Secondary outcome measures were packed red blood cell transfusions, and acute chest syndrome incidence. Patient-controlled analgesia use and promethazine use were assessed to estimate CPW use. Results: Three hundred fourty-four admissions in 112 patients were analyzed, of which 193 admissions occurred pre-CPW and 151 admissions occurred post-CPW implementation. Post-CPW implementation, we observed a significant decrease in hospital admissions annually per patient, an increase in patient-controlled analgesia use, and a decrease in intravenous promethazine use. We observed trends toward decreased 30-day readmission rate and increased acute chest syndrome incidence, which were not statistically significant. No effect was found on hospital LOS. Conclusions: Clinical pathway implementation at our institution reduced variation in management and decreased hospital admissions for vaso-occlusive pain.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

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Clinical Pathway for Vaso-Occlusive Pain Reduces Hospital Admissions

et al. 2021

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“…secondary ACS) ranges from 12.5% to 42%, and the median time to onset is usually between 2-4 days. 3,4,[16][17][18][19][20] However, data on early-onset ACS (i.e. onset less than 24 hours (h) after the VOC) are particularly scarce, and it is not known whether early-onset ACS and secondary ACS have different characteristics.…”

Section: Introductionmentioning

confidence: 99%

Acute chest syndrome in adult patients with sickle cell disease: The relationship with the time to onset after hospital admission

et al. 2023

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Summary Data on acute chest syndrome (ACS) in adult sickle cell disease patients are scarce. In this study, we describe 105 consecutive ACS episodes in 81 adult patients during a 32‐month period and compare the characteristics as a function of the time to onset after hospital admission for a vaso‐occlusive crisis (VOC), that is early‐onset episodes (time to onset ≤24 h, 42%) versus secondary episodes (>24 h, 58%; median [interquartile range] time to onset: 2 [2–3] days). The median age was 27 [22–34] years, 89% of the patients had an S/S or S/β0‐thalassaemia genotype; 81% of the patients had a history of ACS (median: 3 [2–5] per patient), only 61% were taking a disease‐modifying treatment at the time of the ACS. Fever and chest pain were noted in respectively 54% and 73% of the episodes. Crackles (64%) and bronchial breathing (32%) were the main abnormal auscultatory findings. A positive microbiological test was found for 20% of episodes. Fifty percent of the episodes required a blood transfusion; ICU transfer and mortality rates were respectively 29% and 1%. Secondary and early‐onset forms of ACS did not differ significantly. Disease‐modifying treatments should be revaluated after each ACS episode because the recurrence rate is high.

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“…5 Previous studies have shown that utilization of a standard care pathway for all sickle cell patients leads to an increased use of PCAs but also a decrease in total length of stay. 6 Conti and colleagues 7 proposed an oral morphine regimen in an emergency department (ED) setting where IV meperidine had previously been used. They reviewed the ED visits of 9 patients prior to the implementation of the oral morphine protocol and after and noted a statistically significant decrease in total ED visits, length of stay, and number of admissions after the implementation of the oral protocol.…”

Section: Introductionmentioning

confidence: 99%

Opioid Use in Vaso-Occlusive Crisis During Intravenous Opioid Drug Shortage

2022

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Introduction: In October 2017, the Food and Drug Administration announced a shortage of intravenous (IV) opioid medications. Patients with sickle cell disease (SCD) are particularly vulnerable, as high amounts of IV opioid medications are standard therapy during vaso-occlusive crises (VOC). Our institution responded to the crises by implementing IV to oral (PO) conversions of opioid therapies and encouraging multimodal pain management with non-opioid medications. Objectives: The primary objective was the assessment of IV opioid medication utilization before and during the shortage. Secondary objectives included total opioid consumption, length of stay, and prescribing of non-opioid analgesics. Methods: This single-institution retrospective study included patients >18 years of age admitted to adult medicine teams with VOC during February 2017 or February 2018. The amount of opioid medication administered to patients during both periods was assessed, and quantities were then converted to PO morphine milligram equivalents and compared between years. The number of patients receiving scheduled non-opioid medications were also compared. Length of stay and readmissions were compared between years. Results: Between 2017 and 2018, IV opioid use for VOC decreased by 52% on inpatient services, and there was a 34% reduction in overall opioid use. Oral opioid use more than doubled during the period (10.2% in 2017 vs 39.1% in 2018, P < .01). LOS between 2017 and 2018 (6 vs 6 days, P = .4774) and total number of ED visits (27 vs 8, P = .276) were similar. There were significantly fewer 30-day readmissions in 2018 versus 2017 (15 vs 28, P = .025). Conclusion: The implementation of IV opioid restrictions resulted in a decrease in IV opioid use in treatment of VOC in patients with SCD without causing increases in length of stay or readmissions. Oral opioids should be considered an option for VOC management in patients with SCD.

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Hospitalist Management of Vaso-Occlusive Pain Crisis in Patients With Sickle Cell Disease Using a Pathway of Care

Cited by 8 publications

References 30 publications

Clinical Pathway for Vaso-Occlusive Pain Reduces Hospital Admissions

Clinical Pathway for Vaso-Occlusive Pain Reduces Hospital Admissions

Acute chest syndrome in adult patients with sickle cell disease: The relationship with the time to onset after hospital admission

Opioid Use in Vaso-Occlusive Crisis During Intravenous Opioid Drug Shortage

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