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Telfer P, Anie KA, Kotsiopoulou S, Aiken L, Hibbs S, Burt C, Stuart-Smith S, Lugthart S. The acute pain crisis in sickle cell disease: What can be done to improve outcomes? Blood Rev 2024; 65:101194. [PMID: 38553339 DOI: 10.1016/j.blre.2024.101194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/19/2024] [Accepted: 03/17/2024] [Indexed: 04/21/2024]
Abstract
The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.
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Affiliation(s)
- Paul Telfer
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, UK; Department of Haematology, Royal London Hospital, Bart's Health NHS Trust, London, UK.
| | - Kofi A Anie
- Brent Sickle Cell & Thalassaemia Centre, London North West University Healthcare NHS Trust, London, UK
| | | | - Laura Aiken
- Department of Haematology, Royal London Hospital, Bart's Health NHS Trust, London, UK
| | - Stephen Hibbs
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | | | - Sanne Lugthart
- University of Bristol, School of Cellular and Molecular Medicine, Bristol, UK; Department of Haematology, University Hospitals of Bristol, Bristol, UK
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Isa H, Okocha E, Adegoke SA, Nnebe-Agumadu U, Kuliya-Gwarzo A, Sopekan A, Ofakunrin AO, Ugwu N, Hassan AA, Ohiaeri C, Madu A, Diaku-Akinwumi I, Ekwem L, Dogara LG, Okoh D, Jasini J, Girei A, Ekwere T, Okolo A, Kangiwa U, Lawson J, Chianumba R, Brown B, Akinola N, Nwegbu M, Nnodu O. Strategies to improve healthcare services for patients with sickle cell disease in Nigeria: The perspectives of stakeholders. Front Genet 2023; 14:1052444. [PMID: 36816043 PMCID: PMC9936139 DOI: 10.3389/fgene.2023.1052444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Background: Sickle cell disease (SCD) continues to pose physical and psychosocial burdens to patients, caregivers and health workers. Stakeholder engagement in the processes of policy making and implementation is increasingly becoming the cornerstone of best practices in healthcare. Aim and Objectives: To engage stakeholders with a view to assessing the knowledge of SCD; ascertain the challenges associated with accessibility and affordability of healthcare services; improve the quality of care, and thereby effect behavioral change through increasing attendance and follow-up of patients in the clinics. Methodology: A Stakeholders' Engagement meeting organized by the Sickle Pan Africa Research Consortium Nigeria Network (SPARC-NEt) was attended by patients, caregivers and members of patient support groups, healthcare providers and management/policymakers. The engagement was through PowerPoint presentations, structured questionnaires and an interactive session. The structured questionnaire assessed the knowledge of stakeholders about SCD; the quality of healthcare services; challenges with access and affordability; and SCD-related government policies. Results: Three hundred and twelve stakeholders attended the engagement meeting. Of the 133 that participated in the study, medical workers were the most represented. The majority had good knowledge of what causes SCD (96.2%) and the best place to get help during SCD crisis (98.5%). However, knowledge of the specific preventive measures of SCD and its crisis was not optimal. In terms of the role of community engagement and education, only about one-quarter of the study participants, 34 (25.6%) knew about their positive role in reducing the prevalence of SCD and alleviating SCD crises. Challenges identified include inadequate healthcare personnel and facilities, delay in obtaining laboratory results, long waiting time in the clinic, poor communication, absence of holistic consultation, uncoordinated healthcare services, high cost of care, ignorance, non-prioritization of SCD by government, lack of multisectoral collaboration and partnership with NGOs and international organizations. Strategies proffered to improve healthcare services include, community/stakeholder engagement and health education, sickle cell daycare services, access to a willing and dedicated multidisciplinary workforce, collaboration with support groups and government policies and programs. Conclusion: There is need for regular stakeholder engagement to improve access to healthcare services for SCD patients in Nigeria.
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Affiliation(s)
- Hezekiah Isa
- Centre of Excellence for Sickle Cell Research and Training, University of Abuja (CESRTA) Federal Capital Territory (FCT), Abuja, Nigeria,Department of Haematology and Blood Transfusion, University of Abuja, Abuja, Nigeria,*Correspondence: Hezekiah Isa,
| | - Emmanuel Okocha
- Department of Haematology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambara State, Nigeria
| | - Samuel Ademola Adegoke
- Department of Paediatrics and Child health, Obafemi Awolowo University, Ile Ife, Osun State, Nigeria
| | - Uche Nnebe-Agumadu
- Department of Paediatrics, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Aisha Kuliya-Gwarzo
- Department of Haematology, Aminu Kano University Teaching Hospital, Kano, Kano State, Nigeria
| | - Alayo Sopekan
- Non Communicable Disease Unit, Federal Ministry of Health, Federal Secretariat, Abuja, Nigeria
| | | | - Ngozi Ugwu
- Department of Haematology, Alex Ekweme Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - Abdul-Aziz Hassan
- Department of Haematology and Blood Transfusion, Ahmadu Bello University, Zaria, Kaduna State, Nigeria
| | - Chinatu Ohiaeri
- Department of Paediatrics, Federal Medical Centre Keffi, Keffi, Nasarawa State, Nigeria
| | - Anazoeze Madu
- Department of Haematology, University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria
| | - Ijeoma Diaku-Akinwumi
- Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Lagos State, Nigeria
| | - Lilian Ekwem
- Department of Paediatrics, General Hospital Nyanya, Abuja, Nigeria
| | - Livingstone Gayus Dogara
- Departments of Haematology and Blood Transfusion, Kaduna State University Teaching Hospital, Kaduna, Kaduna State, Nigeria
| | - Dorothy Okoh
- Department of Haematology, Rivers State University, Port Harcourt, Rivers State, Nigeria
| | - James Jasini
- Department of Haematology, Federal Medical Centre, Yola, Adamawa State, Nigeria
| | - Ahmed Girei
- Department of Haematology, Federal Teaching Hospital Gombe, Gombe, Gombe State, Nigeria
| | - Timothy Ekwere
- Department of Haematology, University of Uyo, Uyo, Akwa IbomState, Nigeria
| | - Angela Okolo
- Federal Medical Centre Asaba, Asaba, Delta State, Nigeria
| | - Umar Kangiwa
- Department of Haematology, Federal Medical Centre, Birnin Kebbi, Kebbi State, Nigeria
| | - Juliet Lawson
- Department of Paediatrics, Zankli Medical Centre, Abuja, Nigeria
| | - Reuben Chianumba
- Centre of Excellence for Sickle Cell Research and Training, University of Abuja (CESRTA) Federal Capital Territory (FCT), Abuja, Nigeria
| | - Biobele Brown
- Department of Paediatrics, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Norah Akinola
- Department of Haematology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Osun State, Nigeria
| | - Maxwell Nwegbu
- Centre of Excellence for Sickle Cell Research and Training, University of Abuja (CESRTA) Federal Capital Territory (FCT), Abuja, Nigeria,Department of Chemical Pathology, University of Abuja, Abuja, Nigeria
| | - Obiageli Nnodu
- Centre of Excellence for Sickle Cell Research and Training, University of Abuja (CESRTA) Federal Capital Territory (FCT), Abuja, Nigeria,Department of Haematology and Blood Transfusion, University of Abuja, Abuja, Nigeria
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Lanzkron S, Little J, Wang H, Field JJ, Shows JR, Haywood C, Saheed M, Proudford M, Robertson D, Kincaid A, Burgess L, Green C, Seufert R, Brooks J, Piehet A, Griffin B, Arnold N, Frymark S, Wallace M, Abu Al Hamayel N, Huang CY, Segal JB, Varadhan R. Treatment of Acute Pain in Adults With Sickle Cell Disease in an Infusion Center Versus the Emergency Department : A Multicenter Prospective Cohort Study. Ann Intern Med 2021; 174:1207-1213. [PMID: 34224261 DOI: 10.7326/m20-7171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients with sickle cell disease (SCD) have vaso-occlusive crises (VOCs). Infusion centers (ICs) are alternatives to emergency department (ED) care and may improve patient outcomes. OBJECTIVE To assess whether care in ICs or EDs leads to better outcomes for the treatment of uncomplicated VOCs. DESIGN Prospective cohort. (ClinicalTrials.gov: NCT02411396). SETTING 4 U.S. sites, with recruitment between April 2015 and December 2016. PARTICIPANTS Adults with SCD living within 60 miles of a study site. MEASUREMENTS Participants were followed for 18 months after enrollment. Outcomes of interest were time to first dose of parenteral pain medication, whether pain reassessment was completed within 30 minutes after the first dose, and patient disposition on discharge from the acute care visit. Treatment effects for ICs versus EDs were estimated using a time-varying propensity score adjustment. RESULTS Researchers enrolled 483 participants; the 269 who had acute care visits on weekdays are included in this report. With inverse probability of treatment-weighted adjustment, the mean time to first dose was 62 minutes in ICs and 132 minutes in EDs; the difference was 70 minutes (95% CI, 54 to 98 minutes; E-value, 2.8). The probability of pain reassessment within 30 minutes of the first dose of parenteral pain medication was 3.8 times greater (CI, 2.63 to 5.64 times greater; E-value, 4.7) in the IC than the ED. The probability that a participant's visit would end in admission to the hospital was smaller by a factor of 4 (0.25 [CI, 0.18 to 0.33]) with treatment in an IC versus an ED. LIMITATION The study was restricted to participants with uncomplicated VOCs. CONCLUSION In adults with SCD having a VOC, treatment in an IC is associated with substantially better outcomes than treatment in an ED. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute.
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Affiliation(s)
- Sophie Lanzkron
- Johns Hopkins University School of Medicine, Baltimore, Maryland (S.L., H.W., M.S., R.S., J.B., J.S.)
| | - Jane Little
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio (J.L., B.G., N.A.)
| | - Hang Wang
- Johns Hopkins University School of Medicine, Baltimore, Maryland (S.L., H.W., M.S., R.S., J.B., J.S.)
| | - Joshua J Field
- Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin (J.J.F., S.F.)
| | - J Ryan Shows
- Our Lady of the Lake Hospital, Baton Rouge, Louisiana (J.R.S., A.P.)
| | - Carlton Haywood
- The Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland (C.H.J.)
| | - Mustapha Saheed
- Johns Hopkins University School of Medicine, Baltimore, Maryland (S.L., H.W., M.S., R.S., J.B., J.S.)
| | - Marc Proudford
- William E. Proudford Foundation, Baltimore, Maryland (M.P.)
| | - Derek Robertson
- Maryland Sickle Cell Disease Association, Columbia, Maryland (D.R.)
| | | | - Lorri Burgess
- Baton Rouge Sickle Cell Disease Association, Baton Rouge, Louisiana (L.B.)
| | | | - Rebecca Seufert
- Johns Hopkins University School of Medicine, Baltimore, Maryland (S.L., H.W., M.S., R.S., J.B., J.S.)
| | - Jasmine Brooks
- Johns Hopkins University School of Medicine, Baltimore, Maryland (S.L., H.W., M.S., R.S., J.B., J.S.)
| | - Allie Piehet
- Our Lady of the Lake Hospital, Baton Rouge, Louisiana (J.R.S., A.P.)
| | - Brandi Griffin
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio (J.L., B.G., N.A.)
| | - Nicole Arnold
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio (J.L., B.G., N.A.)
| | - Steven Frymark
- Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin (J.J.F., S.F.)
| | - Marcus Wallace
- Louisiana Health Care Connection, Baton Rouge, Louisiana (M.W.)
| | | | - Chiung-Yu Huang
- University of California, San Francisco, San Francisco, California (C.H.)
| | - Jodi B Segal
- Johns Hopkins University School of Medicine, Baltimore, Maryland (S.L., H.W., M.S., R.S., J.B., J.S.)
| | - Ravi Varadhan
- Oncology Biostatistics and Bioinformatics, Johns Hopkins University, Baltimore, Maryland (R.V.)
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Building access to care in adult sickle cell disease: defining models of care, essential components, and economic aspects. Blood Adv 2021; 4:3804-3813. [PMID: 32785684 DOI: 10.1182/bloodadvances.2020001743] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/02/2020] [Indexed: 01/25/2023] Open
Abstract
Sickle cell disease (SCD) is the most common inherited blood disorder in the United States. It is a medically and socially complex, multisystem illness that affects individuals throughout the lifespan. Given improvements in care, most children with SCD survive into adulthood. However, access to adult sickle cell care is poor in many parts of the United States, resulting in increased acute care utilization, disjointed care delivery, and early mortality for patients. A dearth of nonmalignant hematology providers, the lack of a national SCD registry, and the absence of a centralized infrastructure to facilitate comparative quality assessment compounds these issues. As part of a workshop designed to train health care professionals in the skills necessary to establish clinical centers focused on the management of adults living with SCD, we defined an SCD center, elucidated required elements of a comprehensive adult SCD center, and discussed different models of care. There are also important economic impacts of these centers at an institutional and health system level. As more clinicians are trained in providing adult-focused SCD care, center designation will enhance the ability to undertake quality improvement and compare outcomes between SCD centers. Activities will include an assessment of the clinical effectiveness of expanded access to care, the implementation of SCD guidelines, and the efficacy of newly approved targeted medications. Details of this effort are provided.
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American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv 2021; 4:2656-2701. [PMID: 32559294 DOI: 10.1182/bloodadvances.2020001851] [Citation(s) in RCA: 164] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care. OBJECTIVE These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD. METHODS ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery. CONCLUSIONS Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.
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Asnani V, Black KM, Harris J, Knight-Madden J, Asnani M. Use of the daycare ward for the management of acute complications of sickle cell disease in Jamaica: A retrospective review. Int J Clin Pract 2021; 75:e13755. [PMID: 33058372 DOI: 10.1111/ijcp.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Vikram Asnani
- Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica
| | - Kim-Michael Black
- Caribbean Institute for Health Research - Sickle Cell Unit, The University of the West Indies, Kingston 7, Jamaica
| | - June Harris
- Caribbean Institute for Health Research - Sickle Cell Unit, The University of the West Indies, Kingston 7, Jamaica
| | - Jennifer Knight-Madden
- Caribbean Institute for Health Research - Sickle Cell Unit, The University of the West Indies, Kingston 7, Jamaica
| | - Monika Asnani
- Caribbean Institute for Health Research - Sickle Cell Unit, The University of the West Indies, Kingston 7, Jamaica
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Al Zahrani O, Hanafy E, Mukhtar O, Sanad A, Yassin W. Outcomes of multidisciplinary team interventions in the management of sickle cell disease patients with opioid use disorders. A retrospective cohort study. Saudi Med J 2020; 41:1104-1110. [PMID: 33026052 PMCID: PMC7841511 DOI: 10.15537/smj.2020.10.25386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objectives: To identify the magnitude of opioid use disorder (OUD) among sickle cell disease (SCD) patients; emphasize on multidisciplinary team (MDT) role; estimate cost-effectiveness following the proper use of therapeutic guidelines; and facilitate the reduction of emergency room (ER) visits and the length of stay (LOS). Methods: This retrospective cohort study included SCD patients aged 14 years and above, who have OUD. Data was collected between January 2016 and December 2018. Data included ER visits, hospital LOS, opioid consumption, and narcotic prescription tracking. The target group was followed with a set of interventions for pain management and healthcare resource utilization. Results: Twenty one SCD patients were identified with OUD. Following the interventions, there was a statistically significant decrease in ER visits of these OUD patients (from 8709 visits in 2016 to only 94 in 2018). Morphine consumption decreased by 82% and meperidine by 60%, over the 3-year period. Moreover, there was a huge reduction in both ER and LOS costs for this cohort of patients. Conclusion: Establishing an MDT and a series of interventions for SCD patients with OUD, including educational activities for caregivers and patients; establishing a palliative/pain clinic and a SCD addiction clinic; and implementing an adequate opioid prescription tracking system resulted in a significant reduction in both the cost and number of ER visits and hospital LOS and dramatically decreased opioid consumption.
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Affiliation(s)
- Omar Al Zahrani
- Prince Sultan Oncology Center, King Salman North West Armed Forces Hospital, Tabuk, Kingdom of Saudi Arabia. E-mail.
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8
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Myrick R, Blakemore S, Waite E, Pernell B, Madan-Swain A, Hilliard L, Lebensburger J. Outpatient pain clinic and intranasal fentanyl to improve sickle cell disease outcomes. Pediatr Blood Cancer 2020; 67:e28648. [PMID: 32798305 DOI: 10.1002/pbc.28648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute pain events are a leading complication for sickle cell patients. In an attempt to improve pain outcomes, we developed an outpatient pain clinic, and included intranasal fentanyl in the opioid emergency department (ED) pain order set. We evaluated admission rates and opioid administration for patients that attended both the outpatient pain clinic and ED within a 3-month period. METHODS We recorded the admission rate, IV morphine equivalents, and time from triage for each opioid order and administration from both an outpatient pain clinic and ED visit within a 3-month period for an individual pediatric patient with sickle cell disease. RESULTS Thirty patients received acute pain management in both settings. We identified a significant reduction in hospital admission when patients received care in the pain clinic as compared to the ED (17% vs 43%, P = .02). Additionally, outpatient pain clinic patients received significantly less IV morphine equivalents than patients received in the ED (5.6 vs 10.6 IV morphine equivalents, P < .0001). In the ED, intranasal fentanyl was administered in a significantly shorter time than patients ordered intravenous opioid (43 vs 75 min, P = .02). The mean time to receiving an opioid in the outpatient pain clinic was 57 min. CONCLUSION The use of an outpatient pain clinic can reduce admission rates as compared to the ED. The use of intranasal fentanyl reduced the time to first opioid administration in the ED. Patient-centered research or quality improvement projects should continue to focus on novel approaches to acute pain event management.
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Affiliation(s)
| | - Shaundra Blakemore
- Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Brandi Pernell
- Pediatric Hematology Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Avi Madan-Swain
- Pediatric Hematology Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lee Hilliard
- Pediatric Hematology Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey Lebensburger
- Pediatric Hematology Oncology, University of Alabama at Birmingham, Birmingham, Alabama
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Adegoke SA, Oladimeji OI, Ologun BG, Aladekomo TA, Oyelami OA. Outcome of short-term emergency department observation care of children with sickle cell disease and vaso-occlusive crises: initial experience from south-western Nigeria. Trans R Soc Trop Med Hyg 2020; 114:365-371. [PMID: 32181486 DOI: 10.1093/trstmh/traa006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/07/2020] [Accepted: 01/18/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Short-term emergency department (ED) observation care may prevent prolonged and unnecessary hospital admission in patients with sickle pain. This study highlights the outcomes of short-term ED care of acute pain in children with sickle cell disease (SCD). METHODS Children aged 6 mo to 19 y with SCD and painful crises who were managed by short-term ED care from July 2017 to June 2019 were studied retrospectively. Biodata, pain score, type of care, length of hospital stay, inpatient transfer rate (the proportion that required transfer for full admission) and return rate (the proportion that returned to the hospital for retreatment of unresolved pain) were documented. RESULTS From July 2017 to June 2019, 122 children with SCD were admitted to the ED for painful crises, of whom 118 (96.7%) with 167 hospital visits were managed by short-term ED observation care. The median length of stay was 10.5 h. In 50.3% of encounters, patients were successfully managed without requiring further care. However, in 17.4% of encounters, they had their ED observation care terminated and converted to full admission. The overall return rate for acute care within 1 wk for either persistence of symptoms or any other complaint was 31.7%. CONCLUSIONS Dedicated short-term ED observation care has the potential to provide effective and timely management of acute pain in children with SCD.
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Affiliation(s)
- Samuel A Adegoke
- Department of Paediatrics and Child Health, Obafemi Awolowo University (OAU), Ile-Ife, Nigeria
| | - O I Oladimeji
- Department of Paediatrics, Wesley Guild Hospital Ilesa Unit, OAU Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - B G Ologun
- Department of Paediatrics, Wesley Guild Hospital Ilesa Unit, OAU Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - T A Aladekomo
- Department of Paediatrics and Child Health, Obafemi Awolowo University (OAU), Ile-Ife, Nigeria
| | - O A Oyelami
- Department of Paediatrics and Child Health, Obafemi Awolowo University (OAU), Ile-Ife, Nigeria
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Factors affecting length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2020; 8:51-56. [PMID: 31960355 DOI: 10.1007/s43390-020-00042-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency. METHODS A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay. RESULTS Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001). CONCLUSIONS Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS. LEVEL OF EVIDENCE Level III.
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11
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Increased acute care utilization in a prospective cohort of adults with sickle cell disease. Blood Adv 2019; 2:2412-2417. [PMID: 30254105 DOI: 10.1182/bloodadvances.2018018382] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/15/2018] [Indexed: 11/20/2022] Open
Abstract
The ESCAPED (Examining Sickle Cell Acute Pain in the Emergency vs Day Hospital) trial is an ongoing prospective study comparing outcomes of people with sickle cell disease (SCD) seeking care for acute pain management in either an emergency department or specialty infusion clinic. The objective of this paper is to describe the baseline characteristics and health care utilization of patients in the trial. This is a multicenter study across 4 US cities that enrolled all adults with SCD living within 60 miles (96.6 km) of a study site who were expected to have acute care utilization over the study period. Twenty-one percent of participants had no acute care visits in the first 12 months of follow-up. Using negative binomial regression, we describe subject characteristics that predict acute care utilization. Three hundred ninety-one subjects have completed 12 months of follow-up with a mean age of 34.5 years (standard deviation, 11.4), 60% are female. Fifty-four percent of subjects with hemoglobin SS disease and 46% with hemoglobin SC disease had 3 or more acute visits over the study period. The prevalence of chronic pain in this cohort was 68%. Predictors of higher rates of acute care utilization included being unemployed, having chronic pain, being on chronic transfusion therapy, having a history of stroke, and being on disability or on Medicaid. This is the first prospective cohort in the modern era, and it demonstrates much higher rates of acute care utilization than reported in the Cooperative Study of Sickle Cell Disease.
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Oetgen ME, Martin BD, Gordish-Dressman H, Cronin J, Pestieau SR. Effectiveness and Sustainability of a Standardized Care Pathway Developed with Use of Lean Process Mapping for the Treatment of Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Bone Joint Surg Am 2018; 100:1864-1870. [PMID: 30399081 DOI: 10.2106/jbjs.18.00079] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent changes in health care have begun to shift the industry from a volume-based to a value-based focus. This shift has led to standardized care pathways that decrease care variability, improve outcomes, and decrease cost. Although numerous studies have described standardized pathways for adolescent idiopathic scoliosis (AIS), few have demonstrated sustainability. We report the effectiveness and sustainability of a standardized care pathway for patients undergoing posterior spinal fusion for AIS. METHODS A standardized care pathway was developed and implemented (in March 2015) at our pediatric hospital for all patients undergoing posterior spinal fusion for AIS. This pathway was developed with use of the Lean process mapping technique to create an evidence-based protocol for preoperative, operative, postoperative, and post-discharge care. The 44 patients managed prior to implementation of the pathway (pre-pathway group) were compared with the 169 patients managed after implementation (post-pathway group). The post-pathway group was divided into 5 cohorts, each representing a 6-month time period. Clinical outcomes (pain scores, medication requirements, transfusions) and efficiency metrics (length of stay) were used to determine pathway sustainability. RESULTS The pre-pathway group included patients managed in the 8 months prior to implementation (July 2014 to February 2015) and the post-pathway group included patients who underwent surgery from March 2015 to July 2017, divided into 5 cohorts representing 6 months each. Patients in the post-pathway group had lower postoperative pain scores, and used significantly less opioids at each time interval, compared with the pre-pathway group. Perioperative transfusion requirements and postoperative length of stay were significantly lower across all post-pathway cohorts compared with the pre-pathway group. There were no significant differences in clinical results among the 5 post-pathway cohorts. CONCLUSIONS Implementation of a standardized care pathway developed with use of Lean process mapping demonstrated effective and sustained improvements to the care of patients with AIS, as well as decreased postoperative length of stay. These outcomes have been maintained over 2.5 years, indicating that high-quality care for patients with AIS undergoing spinal fusion can be achieved and sustained with use of a standardized care pathway. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Matthew E Oetgen
- Division of Orthopaedic Surgery & Sports Medicine (M.E.O. and B.D.M.), Center for Translational Science (H.G.-D.), and Division of Anesthesiology, Pain and Perioperative Management (J.C. and S.R.P.), Children's National Health System, Washington, DC
| | - Benjamin D Martin
- Division of Orthopaedic Surgery & Sports Medicine (M.E.O. and B.D.M.), Center for Translational Science (H.G.-D.), and Division of Anesthesiology, Pain and Perioperative Management (J.C. and S.R.P.), Children's National Health System, Washington, DC
| | - Heather Gordish-Dressman
- Division of Orthopaedic Surgery & Sports Medicine (M.E.O. and B.D.M.), Center for Translational Science (H.G.-D.), and Division of Anesthesiology, Pain and Perioperative Management (J.C. and S.R.P.), Children's National Health System, Washington, DC
| | - Jessica Cronin
- Division of Orthopaedic Surgery & Sports Medicine (M.E.O. and B.D.M.), Center for Translational Science (H.G.-D.), and Division of Anesthesiology, Pain and Perioperative Management (J.C. and S.R.P.), Children's National Health System, Washington, DC
| | - Sophie R Pestieau
- Division of Orthopaedic Surgery & Sports Medicine (M.E.O. and B.D.M.), Center for Translational Science (H.G.-D.), and Division of Anesthesiology, Pain and Perioperative Management (J.C. and S.R.P.), Children's National Health System, Washington, DC
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Cline DM, Silva S, Freiermuth CE, Thornton V, Tanabe P. Emergency Department (ED), ED Observation, Day Hospital, and Hospital Admissions for Adults with Sickle Cell Disease. West J Emerg Med 2018; 19:311-318. [PMID: 29560059 PMCID: PMC5851504 DOI: 10.5811/westjem.2017.9.35422] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 06/22/2017] [Accepted: 09/12/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Use of alternative venues to manage uncomplicated vaso-occlusive crisis (VOC), such as a day hospital (DH) or ED observation unit, for patients with sickle cell anemia, may significantly reduce admission rates, which may subsequently reduce 30-day readmission rates. Methods In the context of a two-institution quality improvement project to implement best practices for management of patients with sickle cell disease (SCD) VOC, we prospectively compared acute care encounters for utilization of 1) emergency department (ED); 2) ED observation unit; 3) DH, and 4) hospital admission, of two different patient cohorts with SCD presenting to our two study sites. Using a representative sample of patients from each institution, we also tabulated SCD patient visits or admissions to outside hospitals within 20 miles of the patients’ home institutions. Results Over 30 months 427 patients (297 at Site 1 and 130 at Site 2) initiated 4,740 institutional visits, totaling 6,627 different acute care encounters, including combinations of encounters. The range of encounters varied from a low of 0 (203 of 500 patients [40.6%] at Site 1; 65 of 195 patients [33.3%] at Site 2), and a high of 152 (5/month) acute care encounters for one patient at Site 2. Patients at Site 2 were more likely to be admitted to the hospital during the study period (88.4% vs. 74.4%, p=0.0011) and have an ED visit (96.9% vs. 85.5%, p=0.0002). DH was used more frequently at Site 1 (1.207 encounters for 297 patients at Site 1, vs. 199 encounters for 130 patients at Site 2), and ED observation was used at Site 1 only. Thirty-five percent of patients visited hospitals outside their home academic center. Conclusion In this 30-month assessment of two sickle cell cohorts, healthcare utilization varied dramatically between individual patients. One cohort had more hospital admissions and ED encounters, while the other cohort had more day hospital encounters and used a sickle cell disease observation VOC protocol. One-third of patients sampled visited hospitals for acute care outside of their care providers’ institutions.
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Affiliation(s)
- David M Cline
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Susan Silva
- Duke School of Nursing, Duke University Medical Center, Durham, North Carolina
| | - Caroline E Freiermuth
- Duke University Medical Center, Department of Surgery, Division of Emergency Medicine, Durham, North Carolina
| | - Victoria Thornton
- Duke University Medical Center, Department of Surgery, Division of Emergency Medicine, Durham, North Carolina
| | - Paula Tanabe
- Duke School of Nursing, Duke University Medical Center, Durham, North Carolina.,Duke University Medical Center, Department of Surgery, Division of Emergency Medicine, Durham, North Carolina.,Duke University Medical Center, Department of Medicine, Division of Hematology, Durham, North Carolina
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Telfer P, Kaya B. Optimizing the care model for an uncomplicated acute pain episode in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:525-533. [PMID: 29222301 PMCID: PMC6142581 DOI: 10.1182/asheducation-2017.1.525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The pathophysiology, clinical presentation, and natural history of acute pain in sickle cell disease are unique and require a disease-centered approach that also applies general principles of acute and chronic pain management. The majority of acute pain episodes are managed at home without the need to access health care. The long-term consequences of poorly treated acute pain include chronic pain, adverse effects of chronic opioid usage, psychological maladjustment, poor quality of life, and excessive health care utilization. There is no standard protocol for management of an acute pain crisis in either the hospital or the community. The assumptions that severe acute pain must be managed in the hospital with parenteral opioids and that strong opioids are needed for home management of pain need to be questioned. Pain management in the emergency department often does not meet acceptable standards, while chronic use of strong opioids is likely to result in opioid-induced hyperalgesia, exacerbation of chronic pain symptoms, and opioid dependency. We suggest that an integrated approach is needed to control the underlying condition, modify psychological responses, optimize social support, and ensure that health care services provide safe, effective, and prompt treatment of acute pain and appropriate management of chronic pain. This integrated approach should begin at an early age and continue through the adolescent, transition, and adult phases of the care model.
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Affiliation(s)
- Paul Telfer
- Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom; and
| | - Banu Kaya
- Departments of Haematology and Paediatric Haematology, Royal London Hospital, Bart’s Health National Health Service Trust, London, United Kingdom
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An innovative short-stay health care model for treatment of uncomplicated vaso-occlusive crisis in adult sickle cell disease patients in Canada to reduce emergency department utilization. CAN J EMERG MED 2017; 21:55-62. [PMID: 29039292 DOI: 10.1017/cem.2017.413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Patients with sickle cell disease (SCD) with vaso-occlusive crises (VOC) often visit the emergency department (ED) for management of painful episodes. The primary objective of this pilot study was to evaluate the acceptability of a short-stay model for treatment of VOC in SCD outside of the ED in Toronto, Canada. Secondary objectives were to assess patient satisfaction of this model, barriers to its use and comparison of clinical outcomes to a historical control. METHODS Adult SCD patients with symptoms of an uncomplicated VOC between October 2014 to July 2016 were managed according to best practice recommendations in a short-stay unit as an alternative to the local emergency room. Primary outcome of time to first analgesia, and secondary outcome of discharge rate were compared to a historical control at a local ED from 2009-2012. Satisfaction and barriers to use of the ambulatory care delivery model were assessed by patient survey. RESULTS Twenty-one visits were recorded at the short-stay unit during the study period. Average time to first opiate dose was 23.5 minutes in the short-stay unit compared to 100.3 minutes in the ED (p4/5 on Likert scale) except for geographic accessibility (85% response rate, n=18). CONCLUSION This study demonstrated high patient satisfaction and acceptability of a short-stay model for treatment of uncomplicated VOC in adult SCD patients in Toronto, the first of its kind in Canada.
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Abstract
ED observation units (EDOUs) are designed for patients who require diagnostics or therapeutics beyond the initial ED visit to determine the need for hospital admission. Best evidence is that this care be delivered via ordersets or protocols. Occasionally, patients present with conditions that are amenable to EDOU care but fall outside the commonly used protocols. This article details a few of these conditions: abnormal uterine bleeding, allergic reaction, alcohol intoxication, acetaminophen overdose and sickle cell vaso-occlusive crisis. It is not meant to be exhaustive as patient care needs can vary hospital to hospital.
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Affiliation(s)
- Matthew A Wheatley
- Department of Emergency Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive Southeast, Atlanta, GA 30303, USA.
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Molokie RE, Montminy C, Dionisio C, Farooqui MA, Gowhari M, Yao Y, Suarez ML, Ezenwa MO, Schlaeger JM, Wang ZJ, Wilkie DJ. Opioid doses and acute care utilization outcomes for adults with sickle cell disease: ED versus acute care unit. Am J Emerg Med 2017; 36:88-92. [PMID: 28802541 DOI: 10.1016/j.ajem.2017.07.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/11/2017] [Accepted: 07/12/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Acute care units (ACUs) with focused sickle cell disease (SCD) care have been shown to effectively address pain and limit hospitalizations compared to emergency departments (ED), the reason for differences in admission rates is understudied. Our aim was compare effects of usual care for adult SCD pain in ACU and ED on opioid doses and discharge pain ratings, hospital admission rates and lengths of stay. METHODS In a retrospective, comparative cohort, single academic tertiary center study, 148 adults with sickle cell pain received care in the ED, ACU or both. From the medical records we documented opioid doses, unit discharge pain ratings, hospital admission rates, and lengths of stay. FINDINGS Pain on admission to the ED averaged 8.7±1.5 and to the ACU averaged 8.0±1.6. The average pain on discharge from the ED was 6.4±3.0 and for the ACU was 4.5±2.5. 70% of the 144 ED visits resulted in hospital admissions as compared to 37% of the 73 ACU visits. Admissions from the ED or ACU had similar inpatient lengths of stay. Significant differences between ED and ACU in first opioid dose and hourly opioid dose were noted. CONCLUSIONS Applying guidelines for higher dosing of opioids for acute painful episodes in adults with SCD in ACU was associated with improved pain outcomes and decreased hospitalizations, compared to ED. Adoption of this approach for SCD pain in ED may result in improved outcomes, including a decrease in hospital admissions.
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Affiliation(s)
- Robert E Molokie
- University of Illinois at Chicago, College of Medicine, Department of Hematology/Oncology, 820 S. Wood Street Suite 172 CSN (M/C 712), Chicago, IL 60612, United States; Jesse Brown Veterans Administration Medical Center, 820 S. Damen Avenue, MP 111, Chicago, IL 60612, United States; University of Illinois at Chicago, College of Pharmacy, Department of Biopharmaceutical Sciences, 833 S. Wood Street, Chicago, IL 60612, United States.
| | - Chariz Montminy
- University of Illinois Hospital and Health Sciences System, Department of Nursing, 1740 W. Taylor, Chicago, IL 60614, United States.
| | - Corissa Dionisio
- Riley Hospital for Children at Indiana University Health Department of Psychiatry, 705 Riley Hospital Drive, Indianapolis, IN 46202, United States.
| | | | - Michel Gowhari
- University of Illinois at Chicago, College of Medicine, Department of Hematology/Oncology, 820 S. Wood Street Suite 172 CSN (M/C 712), Chicago, IL 60612, United States.
| | - Yingwei Yao
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, 845 S. Damen Avenue, (M/C 802), Chicago, IL 60612, United States; University of Florida, College of Nursing, Department of Biobehavioral Nursing Science, 1225 Center Drive, Room 2203, Gainesville, FL 32610, United States.
| | - Marie L Suarez
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, 845 S. Damen Avenue, (M/C 802), Chicago, IL 60612, United States.
| | - Miriam O Ezenwa
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, 845 S. Damen Avenue, (M/C 802), Chicago, IL 60612, United States; University of Florida, College of Nursing, Department of Biobehavioral Nursing Science, 1225 Center Drive, Room 2203, Gainesville, FL 32610, United States.
| | - Judith M Schlaeger
- University of Illinois at Chicago, College of Nursing, Department of Women, Children and Family Health Science, 845 S. Damen Avenue, (M/C 802), Chicago, IL 60612, United States.
| | - Zaijie J Wang
- University of Illinois at Chicago, College of Pharmacy, Department of Biopharmaceutical Sciences, 833 S. Wood Street, Chicago, IL 60612, United States.
| | - Diana J Wilkie
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, 845 S. Damen Avenue, (M/C 802), Chicago, IL 60612, United States; University of Florida, College of Nursing, Department of Biobehavioral Nursing Science, 1225 Center Drive, Room 2203, Gainesville, FL 32610, United States.
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Berry JG, Rodean J, Hall M, Alpern ER, Aronson PL, Freedman SB, Brousseau DC, Shah SS, Simon HK, Cohen E, Marin JR, Morse RB, O’Neill M, Neuman MI. Impact of Chronic Conditions on Emergency Department Visits of Children Using Medicaid. J Pediatr 2017; 182:267-274. [PMID: 27979584 PMCID: PMC7398048 DOI: 10.1016/j.jpeds.2016.11.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/17/2016] [Accepted: 11/16/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess the impact of chronic conditions on children's emergency department (ED) use. STUDY DESIGN Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the "highest" visit rates. RESULTS The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees). CONCLUSIONS The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.
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Affiliation(s)
- Jay G. Berry
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Matthew Hall
- Children’s Hospital Association, Overland Park, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital and Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - David C. Brousseau
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious, Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer R Marin
- Departments of Pediatrics and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rustin B. Morse
- Children’s Health System of Texas, Dallas, Texas; Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Margaret O’Neill
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Blinder MA, Duh MS, Sasane M, Trahey A, Paley C, Vekeman F. Age-Related Emergency Department Reliance in Patients with Sickle Cell Disease. J Emerg Med 2015; 49:513-522.e1. [DOI: 10.1016/j.jemermed.2014.12.080] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 10/17/2014] [Accepted: 12/21/2014] [Indexed: 11/30/2022]
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Development of a New Adult Sickle Cell Disease Center Within an Academic Cancer Center: Impact on Hospital Utilization Patterns and Care Quality. J Racial Ethn Health Disparities 2015; 3:176-82. [PMID: 26896118 DOI: 10.1007/s40615-015-0142-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/03/2015] [Accepted: 06/11/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND A national shortage of specialized centers with expertise in the management of adults with sickle cell disease (SCD) remains a concerning public health disparity. Yet, there is an abundance of cancer centers whose operational infrastructure is not only suited to the treatment of the oncology patient, but also can provide medical and procedural care essential to the management of the patient with SCD. Our adult SCD center was formally embedded within an academic hospital-based cancer center in 2009. An evaluation of the impact of this new center has been performed. METHODS A retrospective chart review was conducted of all SCD encounters occurring 5 years pre- and post-SCD center establishment. Demographic, clinical, as well as hospital utilization and care quality data were compared. RESULTS The SCD population grew from 22 to 165 patients. Following establishment of the SCD center, patients experienced greater average annual outpatient preventative visits for chronic disease management (1 vs. 4.1) and fewer average hospitalizations yearly (2.4 vs. 1). There was a decrease in hospitalization rates for management of acute pain (50 vs. 23 %), average hospitalization length of stay (12 vs. 6 days), and the proportion of hospital discharges resulting in readmission within 30 days (60 vs. 40 %). Hydroxyurea use among eligible patients increased from 30 to 90 %. CONCLUSION Findings suggest that embedding adult SCD centers within existing cancer centers can positively impact patterns of health care utilization and improve the quality of care.
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Lanzkron S, Carroll CP, Hill P, David M, Paul N, Haywood C. Impact of a dedicated infusion clinic for acute management of adults with sickle cell pain crisis. Am J Hematol 2015; 90:376-80. [PMID: 25639822 DOI: 10.1002/ajh.23961] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/23/2015] [Accepted: 01/28/2015] [Indexed: 11/11/2022]
Abstract
Most adults with sickle cell disease (SCD) receive care for their acute painful episodes in an emergency department (ED) setting. The purpose of this article is to describe the impact of opening a dedicated treatment center for adults with SCD [Sickle Cell Infusion Clinic (SCIC)] on patient outcomes and on hospital discharges for SCD. Descriptive data including demographics, time to first dose of narcotic, and pain scores were collected on patients presenting to the SCIC and ED. Maryland hospital discharge data were obtained from the Maryland Health Services Cost Review Commission. Analyses were conducted using T tests, χ(2) tests, and simple generalized estimating equation regression models accounting for the clustered nature of observations, as appropriate. There were 3,874 visits to the SCIC by 361 unique patients; 85% of those visits resulted in the patient being sent home. During the same time period, there were 3,408 visits to the ED by 558 unique patients with SCD. The overall admission rate from the ED for these patients was 35.9% but decreased significantly over the time period with a rate of 20% in December 2011. There was a significant decrease in readmissions over time for the entire Baltimore Metro area with the likelihood of readmission decreasing by 7% over time. The SCIC model provides adults with SCD access to high quality care that decreases the need for hospital admission. Further research needs to be done to evaluate the cost effectiveness of this model.
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Affiliation(s)
- Sophie Lanzkron
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - C. Patrick Carroll
- Department of Psychiatry and Behavioral Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Peter Hill
- Department of Emergency Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Mandy David
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Nicklaine Paul
- Department of Nursing; Johns Hopkins Hospital; Baltimore Maryland
| | - Carlton Haywood
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
- Core Faculty; Johns Hopkins Berman Institute of Bioethics; Baltimore Maryland
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Koch KL, Karafin MS, Simpson P, Field JJ. Intensive management of high-utilizing adults with sickle cell disease lowers admissions. Am J Hematol 2015; 90:215-9. [PMID: 25469750 DOI: 10.1002/ajh.23912] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 11/25/2014] [Accepted: 11/28/2014] [Indexed: 11/12/2022]
Abstract
A minority of super-utilizing adults with sickle cell disease (SCD) account for a disproportionate number of emergency department (ED) and hospital admissions. We performed a retrospective cohort study comparing the rate of admission before and after the opening of a clinic for adults with SCD. Unique to this clinic was an intensive management strategy, focusing on super-utilizing adults with 12 or more admissions per year. ED/hospital and 30 days re-admission rates were compared, 1 year pre- and post-intervention, for those adults who established in the clinic. Prior to the intervention, 17 super-utilizers, comprising 15% of the pre-intervention cohort (n = 115), accounted for 58% of the total admissions and had an admission rate of 28 per patient-year. When pre- and post-intervention years were compared, rate of ED/hospital admission per patient-year for super-utilizers decreased from 27.9 to 13.5 (P < 0.001), while there was not a significant reduction for the entire cohort (7.1 vs. 6.1, P = 0.84). Similarly, the decrease in rate of 30 day re-admission was larger for the super-utilizers (13.5 per patient-year to 1.8, P < 0.001), than the whole cohort (2.6 per patient-year to 0.7, P = 0.006). Among the super-utilizers, the reduced rate of admission from the pre- to post-clinic intervention year equated to 252 fewer ED/hospital admissions and 227 fewer 30 day re-admissions. This management strategy focusing on super-utilizing adults with SCD lowered admission and 30 day re-admission rate.
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Affiliation(s)
- Kathryn L. Koch
- Department of Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Matthew S. Karafin
- Medical Sciences Institute, BloodCenter of Wisconsin; Milwaukee Wisconsin
- Department of Pathology; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Pippa Simpson
- Department of Pediatrics; Medical College of Wisconsin; Milwaukee Wisconsin
- Children's Research Institute; Milwaukee Wisconsin
| | - Joshua J. Field
- Department of Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
- Medical Sciences Institute, BloodCenter of Wisconsin; Milwaukee Wisconsin
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A Survey of the Pain Management of Acute Painful Crisis among Patients with Sickle Cell Disease at Two Centres in Jamaica. W INDIAN MED J 2014; 63:252-7. [PMID: 25314283 DOI: 10.7727/wimj.2013.333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 02/12/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this survey was to establish the pain management approaches to acute painful crisis (APC) in sickle cell patients at two healthcare facilities and to compare with available guidelines. METHODS A multi-centre observational survey of the management of APC in sickle cell patients was conducted. Data were collected at the Sickle Cell Unit (SCU), Tropical Medicine Research Institute (TMRI) and Accident and Emergency Department (A&E), University Hospital of the West Indies. RESULTS One hundred episodes of uncomplicated APC involving 81 patients managed at the SCU clinic and 64 episodes at the A&E in a total of 28 patients were included in the data set. Drugs used at the SCU included oral morphine, codeine and paracetamol and intramuscular diclofenac. At the A&E, parenteral morphine and pethidine were most commonly used. At the SCU, the mean time to initiation of analgesics was 38 minutes (IQR 25 to 50 minutes); at the A&E, this was 111 minutes (IQR 50 to 150 minutes). At the SCU, the mean duration of stay (DOS) was 2.9 hours (IQR 1.9 to 3.8 hours) with 94% of the patients being discharged home. At the A&E, the mean DOS was 13.0 hours (IQR 8.3 to 16.9 hours) with 93% of the patients being discharged home. The A&E patient group contained multiple high frequency presenters. Documentation of pain severity scores was inconsistent. CONCLUSION The findings of the survey indicate that the management of APC at the two centres is substantially different. Further study is required to investigate patient satisfaction, centre preference and analgesic therapy efficacy.
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Binding A, Valentine K, Poon MC, Sayani FA. Adult Sickle Cell Disease Epidemiology and the Potential Role of a Multidisciplinary Comprehensive Care Center in a City with Low Prevalence. Hemoglobin 2014; 38:312-5. [DOI: 10.3109/03630269.2014.954048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Colombatti R, Perrotta S, Samperi P, Casale M, Masera N, Palazzi G, Sainati L, Russo G. Organizing national responses for rare blood disorders: the Italian experience with sickle cell disease in childhood. Orphanet J Rare Dis 2013; 8:169. [PMID: 24139596 PMCID: PMC4231397 DOI: 10.1186/1750-1172-8-169] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 10/09/2013] [Indexed: 02/01/2023] Open
Abstract
Background Sickle cell disease (SCD) is the most frequent hemoglobinopathy worldwide but remains a rare blood disorder in most western countries. Recommendations for standard of care have been produced in the United States, the United Kingdom and France, where this disease is relatively frequent because of earlier immigration from Africa. These recommendations have changed the clinical course of SCD but can be difficult to apply in other contexts. The Italian Association of Pediatric Hematology Oncology (AIEOP) decided to develop a common national response to the rising number of SCD patients in Italy with the following objectives: 1) to create a national working group focused on pediatric SCD, and 2) to develop tailored guidelines for the management of SCD that could be accessed and practiced by those involved in the care of children with SCD in Italy. Methods Guidelines, adapted to the Italian social context and health system, were developed by 22 pediatric hematologists representing 54 AIEOP centers across Italy. The group met five times for a total of 128 hours in 22 months; documents and opinions were circulated via web. Results Recommendations regarding the prevention and treatment of the most relevant complications of SCD in childhood adapted to the Italian context and health system were produced. For each topic, a pathway of diagnosis and care is detailed, and a selection of health management issues crucial to Italy or different from other countries is described (i.e., use of alternatives for infection prophylaxis because of the lack of oral penicillin in Italy). Conclusions Creating a network of physicians involved in the day-to-day care of children with SCD is feasible in a country where it remains rare. Providing hematologists, primary and secondary care physicians, and caregivers across the country with web-based guidelines for the management of SCD tailored to the Italian context is the first step in building a sustainable response to a rare but emerging childhood blood disorder and in implementing the World Health Organization’s suggestion “to design (and) implement … comprehensive national integrated programs for the prevention and management of SCD".
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Tanabe P, Dias N, Gorman L. Care of children with sickle cell disease in the emergency department: parent and provider perspectives inform quality improvement efforts. J Pediatr Oncol Nurs 2013; 30:205-17. [PMID: 23836847 DOI: 10.1177/1043454213493509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Children with sickle cell disease (SCD) present to the emergency department (ED) with complex medical and behavioral health needs. Little research has been conducted to understand elements necessary to provide a comprehensive approach. We conducted 9 focus groups and 2 individual interviews with ED nurses, ED physicians, parents, 1 SCD nurse practitioner, and 1 SCD hematologist in 6 states. The primary aim of the study was to assess the appropriateness of the Emergency Department Sickle Cell Assessment of Needs and Strengths for pediatric patients. Participants were asked to discuss important aspects of ED management. Transcripts were analyzed according to 5 key decision points, and common themes were identified for each decision. Decisions included triage, analgesic management, diagnostic evaluation, disposition, and high risk evaluation and referrals needed at discharge. Participants identified critical areas that can be used to organize and improve the assessment, management, and disposition/referral decisions in order to provide better care to children with SCD in the ED. Parent input was critical for each decision.
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Tanabe P, Thornton VL, Martinovich Z, Todd KH, Wun T, Lyons JS. The Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS): reliability and validity. Adv Emerg Nurs J 2013; 35:143-53. [PMID: 23636046 PMCID: PMC4140092 DOI: 10.1097/tme.0b013e31828ecbd5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Emergency department (ED) management of adults with sickle cell disease (SCD) is complex and frustrating. The Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS) is a research-based decision support and quality improvement (QI) tool to guide management of individual patients with SCD and can also be used to guide the development of ED protocols and other QI initiatives for this population. The study evaluated ED-SCANS' inter-rater reliability, face and utility validity among clinicians, and construct validity of anxiety, depression, and psychiatric or social service needs among patients. ED nurses and physicians found the ED-SCANS to be useful, relevant, and easy to use. Nurse practitioners can use the ED-SCANS to assess and manage individual patients. Clinical nurse specialists can use the ED-SCANS as a framework to guide departmental QI efforts.
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Affiliation(s)
- Paula Tanabe
- School of Nursing and Medicine, Duke University, Durham, NC 27713, USA.
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The impact of race and disease on sickle cell patient wait times in the emergency department. Am J Emerg Med 2013; 31:651-6. [PMID: 23380119 DOI: 10.1016/j.ajem.2012.11.005] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 11/13/2012] [Indexed: 11/23/2022] Open
Abstract
STUDY OBJECTIVE To determine whether patients with sickle cell disease (SCD) experience longer wait times to see a physician after arrival to an emergency department (ED) compared to patients with long bone fracture and patients presenting with all other possible conditions (General Patient Sample), and to attempt to disentangle the effects of race and disease status on any observed differences. METHODS A cross-sectional, comparative analysis of year 2003 through 2008 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of nonfederal emergency department visits in the United States. Our primary outcome was wait time (in minutes) to see a physician after arrival to an ED. A generalized linear model was used to examine ratios of wait times comparing SCD visits to the two comparison groups. RESULTS SCD patients experienced wait times 25% longer than the General Patient Sample, though this difference was explained by the African-American race of the SCD patients. SCD patients waited 50% longer than did patients with long bone fracture even after accounting for race and assigned triage priority. CONCLUSIONS Patients with SCD presenting to an ED for care experience longer wait times than other groups, even after accounting for assigned triage level. The African-American race of the SCD patients, and their status as having SCD itself, both appear to contribute to longer wait times for these patients. These data confirm patient anecdotal reports and are in need of intervention.
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Benchmarking pain outcomes for children with sickle cell disease hospitalized in a tertiary referral pediatric hospital. Pain Res Manag 2012; 17:291-6. [PMID: 22891195 DOI: 10.1155/2012/614819] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Painful vaso-occlusive crisis (VOC) is the most common reason for hospitalization in children with sickle cell disease. OBJECTIVE To benchmark pain outcomes in sickle cell disease, including process outcomes (eg, pain assessment and documentation practices, pain management interventions) and clinical outcomes (eg, pain intensity over hospital stay), to identify areas for improvement. METHODS A retrospective study was conducted on electronic charts of children hospitalized with a primary diagnosis of VOC between July 2007 and August 2008. RESULTS A convenience sample of 50 admissions was used. In terms of clinical outcomes, patients presented to the emergency department with an initial median pain intensity of 9⁄10 (interquartile range 8⁄10 to 10⁄10). Forty-three per cent had not used opioids for pain relief at home. The mean (± SD) length of stay was 4.0±2.3 days. For most patients, median scores for highest daily pain intensity remained moderate to high throughout hospitalization, although scores did decrease significantly per day of hospitalization. In terms of process outcomes, pain intensity was assessed according to hospital standards on 25% of days in both the emergency department and the ward. There was no discrepancy between prescribed and administered opioid doses and medication use. In 95% of cases, strong opioid use was in a subtherapeutic or low therapeutic dosage range. CONCLUSIONS The results showed three areas to target for improvement: improved pain assessment and documentation using valid pain tools; more aggressive multimodal management for peak VOC pain; and better education and support for pain management at home. Further studies are required to evaluate optimal pain treatment practices.
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Green SA, Aljuburi G, Majeed A, Okoye O, Amobi C, Banarsee R, Phekoo KJ. Characterizing emergency admissions of patients with sickle cell crisis in NHS brent: observational study. JRSM SHORT REPORTS 2012; 3:37. [PMID: 22768371 PMCID: PMC3386659 DOI: 10.1258/shorts.2012.011129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives To characterize emergency admissions for patients with sickle cell crisis in NHS Brent and to determine which patients and practices may benefit most from primary care intervention. Design Observational study Setting Emergency departments attended by residents of the London borough of Brent Participants Patients with sickle cell disease registered with a general practitioner (GP) in the borough of Brent Main outcome measures Analysis of admissions between January 2008 and July 2010 that included length of stay (average and <2 days versus ≥2 days) by age group and registered GP practice. Results Thirty six percent of sickle cell disease admission spells resulted in a length of stay of less than two days. Seventy four percent of total bed days are associated with patients with more than one admission during the period of analysis, i.e. multiple admissions. Two general practices in Brent were identified as having the highest number of patients admitted to the emergency department for sickle cell crisis and may benefit most from primary care intervention. Discussion Patients with short length of stay and multiple admissions may be potentially amenable to primary care intervention. The practices which have the highest numbers of sickle cell disease patients who frequently seek emergency care will be earmarked for an education intervention designed to help further engage general practitioners in the care and management of their sickle cell patients.
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Affiliation(s)
- Stuart A Green
- NIHR CLAHRC for Northwest London, Imperial College London , London SW10 9NH , UK
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Campbell AD, Ross PT, Kumagai AK, Christner JG, Lypson ML. Coming of Age With Sickle Cell Disease and the Role of Patient as Teacher. J Natl Med Assoc 2010; 102:1073-8. [DOI: 10.1016/s0027-9684(15)30735-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Pain Management in Adults With Sickle Cell Disease in a Medical Center Emergency Department. J Natl Med Assoc 2010; 102:1025-32. [DOI: 10.1016/s0027-9684(15)30729-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wilkie DJ, Johnson B, Mack AK, Labotka R, Molokie RE. Sickle cell disease: an opportunity for palliative care across the life span. Nurs Clin North Am 2010; 45:375-97. [PMID: 20804884 DOI: 10.1016/j.cnur.2010.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Sickle cell disease is a chronic illness that affects patients physically and emotionally and can do so at an early age. An ecological model of palliative care that involves improved communication among the health care team, patients, and their families can be beneficial. Open and honest communication regarding advance care planning, disease management, relief of pain and other symptoms, and bereavement and grief are all important for the patient, family, and health care team. Given the multiple acute and chronic complications of sickle cell disease, an approach to care that is holistic and comprehensive may help to improve a patient's biologic function and the perceived health, functional status, and quality of life of the patient and family.
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Affiliation(s)
- Diana J Wilkie
- Department of Biobehavioral Health Science (MC 802), Center for End-of-Life Transition Research, University of Illinois at Chicago, 845 South Damen Avenue, Room 660, Chicago, IL 60612-7350, USA.
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Imbach P. Day hospital versus inpatient management: An economic initiative of a pediatric center, examplified on uncomplicated vaso-occlusive crises of children with sickle cell disease. Pediatr Blood Cancer 2008; 51:317. [PMID: 18383149 DOI: 10.1002/pbc.21560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Paul Imbach
- Department of Haematology/Oncology, University of Basel, CH-40005 Basel, Switzerland.
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Raphael JL, Kamdar A, Wang T, Liu H, Mahoney DH, Mueller BU. Day hospital versus inpatient management of uncomplicated vaso-occlusive crises in children with sickle cell disease. Pediatr Blood Cancer 2008; 51:398-401. [PMID: 18300322 DOI: 10.1002/pbc.21537] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Day hospital (DH) management for patients with sickle cell disease (SCD) experiencing uncomplicated vaso-occlusive pain crises has been utilized as an alternative care delivery system to inpatient hospitalization. The objective of this study was to determine whether DH management results in shorter length of stay compared to inpatient care. PROCEDURE We conducted a retrospective cohort study with 35 DH admissions and 35 inpatient admissions for children with SCD presenting with uncomplicated vaso-occlusive crises (VOCs). A DH admission was defined as a minimum of two consecutive days of aggressive pain management as an outpatient, including intravenous hydration and analgesics, supported by home treatment over night with oral analgesic and anti-inflammatory agents. We gathered data on demographics, pain scores, length of stay, admission charges, and needs for persistent care. RESULTS DH care resulted in a 39% reduction of the average length of stay compared to inpatient admissions. Multivariate linear regression demonstrated that the location of patient care for VOCs was a significant predictor of length of stay (P < 0.0006) after controlling for patient characteristics, severity of illness, and disease history. CONCLUSIONS We conclude that a dedicated DH facility has the potential to provide efficient and timely management of uncomplicated VOCs through reduction of length of stay. This delivery care system may be particularly relevant for children who are significantly impacted by inpatient hospitalization.
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Affiliation(s)
- Jean L Raphael
- Baylor College of Medicine, Pediatrics, Texas Children's Cancer Center, Houston, Texas, USA.
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Raphael JL, Kamdar A, Beavers MB, Mahoney DH, Mueller BU. Treatment of uncomplicated vaso-occlusive crises in children with sickle cell disease in a day hospital. Pediatr Blood Cancer 2008; 51:82-5. [PMID: 18383165 DOI: 10.1002/pbc.21483] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Day hospital management for patients with sickle cell disease experiencing uncomplicated vaso-occlusive pain crises has been described in adult populations as an alternative care delivery system. The objective of this study was to characterize and descriptively assess the benefits of a day hospital exclusively designed for children. PROCEDURE We retrospectively studied all admissions to the Day Hospital at the Texas Children's Sickle Cell Center since its inception in 2000. A Day Hospital admission was defined as a minimum of two consecutive days of aggressive pain management as an outpatient, including intravenous hydration and analgesics, supported by home treatment over night with oral analgesic and anti-inflammatory agents. We gathered data on demographics, incoming pain score, provider type, opioid administration, length of stay, and needs for higher level care. RESULTS A total of 35 patients, ages 2-19, accounted for 80 episodes during the study period. The median incoming pain score was 8 on a scale from 1 to 10. The median length of stay was 2 days. The return rate for acute care within 48 hr for persistent symptoms was 7%. Seventy-one percent of patients admitted to the Day Hospital were treated without requiring transfer to inpatient care for escalating pain or medical needs. CONCLUSIONS We conclude that a dedicated Day Hospital facility has the potential to provide patient-centered, effective, and timely management of vaso-occlusive crises in children as well as adults.
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Affiliation(s)
- Jean L Raphael
- Baylor College of Medicine, Pediatrics, Texas Children's Cancer Center, Houston, Texas, USA.
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Benjamin L. Pain management in sickle cell disease: palliative care begins at birth? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2008; 2008:466-474. [PMID: 19074128 DOI: 10.1182/asheducation-2008.1.466] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
People with sickle cell disease (SCD) are living longer, but their lives are impacted even more by the unpredictable intermittent or constant pain that is often poorly managed over a lifetime. To address this problem, an interdisciplinary team approach is needed that brings the medical professionals together for optimal compassionate care that is coordinated from the beginning of life and throughout the patient's lifespan.The hematologist, whenever possible, should take the lead. Effective models that have been developed to address SCD pain, such as the Day Hospital, The Recidivism Project and various Home Care models, need to be integrated into an overarching plan on a continuum with an underpinning philosophy that will sustain such a program. While the focus of palliative care has been end of life, its philosophies fit the chronic disease model and support an integrated team approach to the SCD pain management dilemma. The patient-focused and family-oriented interventions can be modeled to fit "any place, any time," outpatient, inpatient or the home, with homecare and other support systems. Such are the needs in SCD: appropriate, timely and compassionate care to prevent or relieve suffering and to preserve dignity, meaning, value and quality of life with improvement that is translational from birth until the end of life.
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Affiliation(s)
- Lennette Benjamin
- Comprehensive Sickle Cell Center, Montefiore Medical Center, New York, NY, USA.
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Treatment and prevention of pain due to vaso-occlusive crises in adults with sickle cell disease: an educational void. Blood 2007; 111:997-1003. [PMID: 17940207 DOI: 10.1182/blood-2007-07-089144] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pain due to vaso-occlusive crisis is the major cause of hospital use in sickle cell disease. Although available guidelines provide recommendations for opioid administration in this setting, only 4 (21%) of 19 medical textbooks present treatment regimens that are consistent with them. Moreover, only 7 texts (37%) note that addiction is infrequent in this population, while 11 (92%) of 12 texts provide such reassurance for cancer-related pain (P < .005). Finally, hydroxyurea use to decrease the frequency of vaso-occlusive crises is completely defined only in 2 textbooks. Thus, most medical texts provide neither adequate information for the treatment or prevention of pain due to vaso-occlusive crisis in sickle cell disease nor reassurance of the unlikelihood of addiction in this population. In contrast, treatment recommendations for less common hematologic disorders are consistent with current standards in 53% to 84% of appropriate texts (P < .05). Limited knowledge regarding the principles and appropriateness of opioid therapy; a lack of evidence-based research on pain control; and misconceptions and prejudices about drug abuse and addiction contribute to this educational void. Thus, research and training on pain control in sickle cell disease are needed to parallel studies of environmental and genetic factors contributing to the known clinical heterogeneity of this disorder.
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Charles KS, Osagie K, Battini RK. Hospital admissions for acute painful crisis in Trinidad and Tobago. Are the British Committee for Standards in Haematology (BCSH) guidelines applicable? CLINICAL AND LABORATORY HAEMATOLOGY 2006; 28:299-302. [PMID: 16999718 DOI: 10.1111/j.1365-2257.2006.00804.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We observed consecutive hospital admissions for acute painful crisis (APC) among adults with Sickle Cell Disease (SCD) over a 6-month period in Trinidad and Tobago. Episodes (111) of APC resulted in 82 admissions of 59 patients. The most common site for pain was the trunk. Patients ranged in age from 17 to 53 years (median: 25). Median length of hospital stay was 4 days. Total dose of Pethidine given per admission ranged from 100 to 1650 mg (median: 525). The mean dose of morphine was 70 mg. Six (7%) of patients were readmitted within 10 days of discharge. Twenty-five (30%) of patients had chest pain at presentation of whom 10 (12%) had consolidation on chest X-ray, defining the acute chest syndrome (ACS). There was one death caused by biliary sepsis. The study revealed seemingly low opiate usage for in-hospital treatment of APC with acceptable rates of readmission. The BCSH 2003 guidelines seemed applicable apart for the choice and route of fluid for rehydration and opiate analgesia.
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Affiliation(s)
- K S Charles
- Haematology Department, General Hospital, Charlotte Street, Port of Spain, Trinidad and Tobago.
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Abstract
OBJECTIVES Sickle cell disease (SCD) is an inherited blood disorder characterized by recurrent 'crisis' pain, which is the most common reason for repeated hospital admission. The nature of this pain, however, is poorly understood, and the pain is often sub-optimally managed. METHODS A focus group format, interpreted using thematic analysis, was used to gain a greater understanding of the barriers that SCD patients face in managing their pain and their perceptions of the treatment that they receive from healthcare professionals. RESULTS Key issues emerging from the focus groups that adversely affected participants' pain management included: feeling isolated by their experience of 'crisis' pain, not being listened to, and limitations to social support networks. Specific issues relating to seeking medical care included lack of understanding about SCD by nonspecialist clinicians, feelings of being low priority due to the 'invisible' nature of their pain, and feeling mistrusted by medical staff when seeking analgesia. DISCUSSION Feelings of isolation may drive maladaptive coping strategies and manifest in anger, aggression and active avoidance of service use. Suggested service improvements include the active targeting of isolated individuals in the form of pain discussion groups or self-help groups, and greater provision of specialised services.
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Affiliation(s)
- Matthew J Booker
- University of Birmingham Medical School, Edgbaston, Birmingham, B15 2TT, UK
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Dumaplin CA. Avoiding admission for afebrile pediatric sickle cell pain: pain management methods. J Pediatr Health Care 2006; 20:115-22; quiz 123-5. [PMID: 16522488 DOI: 10.1016/j.pedhc.2005.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Christine Anne Dumaplin
- Department of Cardiovascular Surgery, Miami Children's Hospital, 3200 SW 60th Court, Suite 102, Miami, FL 33155-3009, USA.
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Abstract
The first of this two-part series highlighted how sickle cell disorders were the most common genetic disorder in the UK. It also described how recurrent sickle cell painful episodes led to many social restrictions on a sufferer's life. In the UK, painful episodes still remain the main reason for the hospital admission of people with sickle cell disease. This often means lengthy periods spent as an inpatient for many sufferers, as well as a lifetime reliant upon health professionals to prescribe strong analgesics in an attempt to try and control the painful symptoms associated with sickle cell disease. Readers should note that the term 'painful episode' is now used in preference to 'crisis'. Despite recommendations that initial hospital management of sickle cell painful episode should be aimed at providing rapid pain control, this article will show that choosing the right analgesic is not always easy to decide. National guidelines may aid this process, incorporated alongside increased patient empowerment and the important role of the nurse.
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Affiliation(s)
- Diana De
- School of Care Science, University of Glamorgan, Pontypridd
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