The association between timely opioid administration and hospitalization in children with sickle cell disease presenting to the emergency department in acute pain

Abstract

Introduction The National Heart, Lung, and Blood Institute guidelines for sickle cell disease (SCD) pain crisis management recommend opioids within 60 minutes of emergency department (ED) registration and every 30 minutes thereafter until acute pain is managed. These guidelines are based on expert opinion without published, supporting data. Objective To evaluate the association between timely ED opioid administration and hospitalization rates in children with SCD. Methods Retrospective cohort of children presenting to a children's hospital ED with SCD pain between January 1, 2014, and April 30, 2018. Visits were extracted using ICD codes, chief complaints, and receipt of at least one opioid, and then reviewed to confirm the visit was an uncomplicated pain crisis. The primary outcome was hospitalization, yes or no. Generalized estimating equations were used to determine adjusted odds of hospitalization for the timely administration of initial and second doses of opioids. Results Of the 902 eligible visits, 368 (40.8%) resulted in hospitalization. The mean (SD) age was 11.9 (± 5.2) years. The first opioid was administered within 60 minutes of arrival in 601 (66.6%) visits. The second opioid was administered within 30 minutes of the first in 84 (12.3%) visits. Receipt of the first opioid within 60 minutes of arrival was not associated with decreased hospitalization (1.30 [0.96‐1.76]). However, receipt of the second dose within 30 minutes of the first was associated with decreased hospitalization (0.56 [0.33‐0.94]). Conclusion This study suggests an association between children with SCD receiving a second dose within 30 minutes of the first opioid dose and decreased hospitalizations.

Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso‐occlusive pain: A multicenter pediatric emergency medicine perspective

“…Our findings support the observation by Kavanagh and colleagues that demonstrated a 32%–48% increase in the proportion of children with SCD‐VOE who were discharged from the ED in a quality improvement initiative that focused on an initial dose of intranasal fentanyl, standardizing care, implementing a pain medication calculator, and education of providers and caregivers 12 . Akinsola and colleagues found a significantly higher discharge rate in patients receiving intranasal fentanyl compared to those receiving IV opioids only (48% vs. 71%, p = .004) in a prospective quality improvement initiative, 10 while results from other single center studies have differed 4,15 . It is possible that the other interventions in the study by Kavanagh et al may have also contributed to greater rates of ED discharge and not the intranasal fentanyl alone.…”

“…12 Akinsola and colleagues found a significantly higher discharge rate in patients receiving intranasal fentanyl compared to those receiving IV opioids only (48% vs. 71%, p = .004) in a prospective quality improvement initiative, 10 while results from other single center studies have differed. 4,15 It is possible that the other interventions in the study by Kavanagh et al may have also contributed to greater rates of ED discharge and not the intranasal fentanyl alone. However, the use of a population from 20 sites in the United States and Canada adds further evidence in support of the use of intranasal fentanyl.…”

“…SCD‐VOE is a medical emergency and helping patients achieve timely relief from VOE‐related pain is paramount. Results from one study suggest that timely administration of intravenous (IV) opioids for SCD‐VOE may be associated with reduced odds of hospital admission from the emergency department (ED), 4 though other studies have not shown the same association 5 …”

“…SCD-VOE is a medical emergency and helping patients achieve timely relief from VOE-related pain is paramount. Results from one study suggest that timely administration of intravenous (IV) opioids for SCD-VOE may be associated with reduced odds of hospital admission from the emergency department (ED), 4 though other studies have not shown the same association. 5 Intranasal fentanyl is a safe and effective analgesic in children [6][7][8] that may circumvent challenges associated with the administration of other initial parenteral opioids 9 and may reduce the time to administration of initial opioid treatment among children presenting to the ED with pain.…”

Return visit rates after an emergency department discharge for children with sickle cell pain episodes

“…[11][12][13] Consistent with the goal of improved ED care decreasing hospitalizations, a single-site study showed guideline-adherent care decreased hospitalization for children experiencing acute pain episodes. 14 While current research indicates ED care is delayed 15,16 and many individuals with SCD are not satisfied with the care they receive, 17,18 there are no data regarding post-ED care quality. However, if guideline-adherent ED care is provided and results in decreased hospitalization, it is essential to determine if this care results in more patients returning to the ED after being discharged home.…”