scholarly journals Impact of emergency department care on outcomes of acute pain events in children with sickle cell disease

2016 ◽  
Vol 91 (12) ◽  
pp. 1175-1180 ◽  
Author(s):  
Amanda M. Brandow ◽  
Mark Nimmer ◽  
Timothy Simmons ◽  
T. Charles Casper ◽  
Lawrence J. Cook ◽  
...  
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Acute Pain ◽  
Cell Disease ◽  
Emergency Department Care

Treatment of Acute Pain in Adults With Sickle Cell Disease in an Infusion Center Versus the Emergency Department

2021 ◽  
Author(s):  
Sophie Lanzkron ◽  
Jane Little ◽  
Hang Wang ◽  
Joshua J. Field ◽  
J. Ryan Shows ◽  
...  
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Acute Pain ◽  
Cell Disease

scholarly journals Acute Care in the Emergency Department Differs before and after Transition for Adolescents and Young Adults with Sickle Cell Disease

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 3267-3267
Author(s):  
Nathan R. Stehouwer ◽  
Bohyung Park ◽  
Preston Edge ◽  
Hong Li ◽  
Connie M. Piccone ◽  
...  
Keyword(s):  
Emergency Department ◽  
Young Adults ◽  
Sickle Cell Disease ◽  
Acute Care ◽  
Sickle Cell ◽  
Acute Pain ◽  
Medication Administration ◽  
Wait Times ◽  
Cell Disease ◽  
Transition Age

Abstract Background Painful vaso-occlusive crises (VOC) are the most common cause of emergency department (ED) visits in patients with sickle cell disease (SCD) and are a major point of contact between patients and the health care system. Transition from pediatric to adult care has not been studied in the acute care setting. We examined whether management of VOC in adolescents and young adults differed between the pediatric and the adult ED. Methods A retrospective chart review was performed for all ED encounters in our hospital system for acute pain in patients with SCD, ages 13-23 years, between 2011-2013. Comprehensive medication administration data was collected for the ED visit as well as for the ensuing hospitalization, when applicable. Demographics and baseline medical data were collected. The equianalgesic dose, expressed as mg of intravenous (IV) morphine, and time to first analgesic administration were calculated. Equianalgesic dose and time to first analgesic were compared between the pediatric and adult ED using analysis of variance. In patients who were hospitalized, the total opioid dose received in the first 24 hours and the mean daily total opioid dosage during hospitalization were compared. Results were adjusted for correlation within multiple visits by individual patients, baseline hemoglobin, and presenting pain scores. Results: 193 visits by 45 subjects, half of whom were male (44% M pediatric, 56% M adults), and most of whom had either HbSS or HbSβ0 (59% pediatric, 83% adults), were examined. Time to medication administration in the pediatric ED was 72 minutes vs 131 minutes in the adult ED (p<0.05, Figure 1A). Opioid medications were administered in 96% of all visits. The adjusted equianalgesic dose of the first opioid medication was 5.4 mg and 10.6 mg in the pediatric and the adult ED, respectively (p<0.0001, Figure 1B). The first opioid administered was parenteral hydromorphone in 4% of pediatric visits and 72% of adult visits. Preliminary analysis suggests that transition-age patients also received higher medication dosages during ensuing admissions to the adult hospital when compared with the pediatric hospital. In a secondary analysis of 5 patients seen in both the pediatric and adult EDs during the study period, wait times were 56 and 158 minutes (p<0.05), and the equianalgesic doses of the first opioid administered were 4.7 mg and 7 mg, respectively (p<0.05). Conclusions These data suggest significant differences in acute pain management between pediatric and adult hospitals for transition-age patients with SCD. Possible reasons for observed differences include a larger patient volume in the adult ED, increasing disease severity with age, and the preference for use of higher potency hydromorphone among adult providers. Our data suggest that optimal transition management for adolescents with SCD must include strategies for transition in acute care management, focusing on limiting wait times and consistent dosing and titration of pain medications. Disclosures No relevant conflicts of interest to declare.

scholarly journals Painful Transitions—a Comparison of Acute Pain Management in Children, Adolescents and Young Adults with Sickle Cell Disease in Adjacent Pediatric and Adult Emergency Departments

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4700-4700
Author(s):  
Brian Pennarola ◽  
Patrick Demartino ◽  
Dale W. Steele ◽  
Susan J. Duffy
Keyword(s):  
Emergency Department ◽  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Acute Pain ◽  
Primary Outcome ◽  
Patient Specific ◽  
Cell Disease ◽  
Opioid Dose ◽  
Electronic Alerts

Abstract Introduction: Qualitative research identifies delayed analgesia and under-dosing as common reasons for patient/caregiver dissatisfaction with the treatment of acute vaso-occlusive pain in sickle cell disease (SCD). Experts have identified quality measures for emergency department (ED) management of acute pain in SCD including early administration of IV analgesics (NHLBI 2014). Adolescent and young adult (AYA) patients are especially at risk for dissatisfaction, and qualitative studies identify the transition from pediatric (PED) to adult emergency department (AED) care as the most difficult site of transition. Information from empirical studies of SCD pain management in PEDs and AEDs is needed to facilitate overall improvements in care and facilitate transitions of care for AYA patients. The goal of this study was to examine differences in management of SCD pain between a PED and an AED. The primary outcome was time from triage to first opioid. Methods: We retrospectively reviewed patients with SCD and acute pain, age 3 - 27 years, seeking care from June 2015 to December 2016 in the AED and/or PED within our academic, tertiary care institution. Four visits per individual per ED were abstracted. Visits were excluded if no opioid was administered, for confounding sources of pain (e.g. post-operative), transfer from another ED or critical illness. Important encounter characteristics and outcomes were summarized by mean with standard deviation (SD) or median with interquartile range (IQR) for skewed data. We compared the difference between EDs for the primary outcome using a Cox proportional hazards model with a patient-level random effect. Results: Our initial electronic health record query yielded 353 visits by 66 patients to the PED and AED. Two patients accounted for 46% of visits (77 and 84 visits). After excluding visits by patients transferred from an outside facility (n=1), with confounding illness (n=6) or no opioid administered (n=3), we extracted data on up to 4 visits per ED per patient and analyzed 127 visits by 55 patients. Demographics, initial pain score, treatments and treatment timeline are summarized by ED (Table 1). The Kaplan-Meier plot (Figure 1) shows the proportion of patients receiving the first intravenous opioid dose, by ED, as a function of time from triage. At any given time, the probability of receiving the first opioid dose in the PED was approximately 3 times greater than in the AED (hazard ratio of 2.95 (95% CI 1.93, 4.50), p < 0.001). Patients in the AED were more likely to receive hydromorphone than morphine and adjunctive NSAIDs were rarely given. More than an hour elapsed between the 1st and 2nd opioid doses in both EDs. Intravenous hydration with normal saline boluses was common in both EDs. An individualized prescribing and monitoring protocol, written by the patient's SCD provider (pain plan) was rarely available to ED providers. Conclusions: Optimal management of acute pain in patients with SCD is difficult, a challenge exacerbated by practice and cultural differences in pediatric versus adult settings. Considering the primary outcome, the PED administered IV analgesia more quickly than the AED, although neither site provided treatment consistently within 30 minutes from triage as per the NHLBI guidelines. Much of the delay in time to first opioid in the AED (Figure 1) is explained by longer rooming times. Our data are limited in that we cannot differentiate whether the delay is due to longer overall wait times or lower prioritization of patients. Nonetheless, this difference remains a known driver of patient dissatisfaction. Our results highlight multiple opportunities in both EDs to improve care including earlier administration and individualized dosing of opioids, reducing the time interval between subsequent doses, routine administration of NSAIDs, avoidance of fluid boluses in euvolemic patients and development of patient specific pain plans. Emergency providers could benefit from education and localized practice guidelines with written protocols and electronic alerts, targeted at quality improvement. The AED could also potentially benefit from focused effort to reduce time from triage to room. Subspecialty providers could assist the ED by routinely providing pain plans; this could help achieve more uniform care across individual encounters in both EDs, particularly in the few patients accounting for a large proportion of all encounters. Disclosures No relevant conflicts of interest to declare.

Variation in Pediatric Emergency Department Care of Sickle Cell Disease and Fever

2015 ◽  
Vol 22 (4) ◽  
pp. 423-430 ◽  
Author(s):  
Angela M. Ellison ◽  
Cary Thurm ◽  
Evaline Alessandrini ◽  
Shabnam Jain ◽  
John Cheng ◽  
...  
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Pediatric Emergency ◽  
Pediatric Emergency Department ◽  
Cell Disease ◽  
Emergency Department Care
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