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Reich J, Cantrell MA, Smeltzer SC. An Integrative Review: The Evolution of Provider Knowledge, Attitudes, Perceptions and Perceived Barriers to Caring for Patients with Sickle Cell Disease 1970-Now. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2023; 40:43-64. [PMID: 35854420 DOI: 10.1177/27527530221090179] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Approximately 100,000 Americans have sickle cell disease (SCD). In the USA, the majority of patients with SCD are of African descent. Due to persistent racial and ethnic disparities in healthcare in the USA, patients with SCD experience disproportionately more health inequities because of providers' implicit biases regarding patient race. Lack of access to health insurance, lack of transportation to healthcare providers, and inadequate provider knowledge contribute to the morbidity and mortality of patients with SCD. The purpose of this integrative review was to analyze and synthesize the literature on providers' knowledge, perceptions, beliefs, and attitudes toward patients with SCD. A modified (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) method was used to conduct a comprehensive review of the literature yielding 31 publications included in this review. Three connected, yet distinct areas of focus were identified: (1) providers' knowledge, attitudes, and perceptions of patients with SCD; (2) providers' perceived or true barriers to caring for patients with SCD; and (3) interventions to improve providers' attitudes, perceptions, and care of patients with SCD. In each area of focus, research has evolved over time. Also included in this integrative review is a synthesis of measurement instruments used to assess provider knowledge, attitudes, perceptions, and perceived and true barriers to caring for patients with SCD. Adolescents with SCD who are transitioning from pediatric to adult care are at a particularly high risk for morbidity and mortality, so this review focused on the many opportunities that exist to advance the healthcare for young adults with SCD to improve patient outcomes later in life. This includes improving providers' knowledge, perceptions, beliefs, and attitudes, and lessening the real or perceived barriers to care for patients with SCD.
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Affiliation(s)
- Jessie Reich
- M. Louise Fitzpatrick College of Nursing, 16196Villanova University, Villanova, PA, USA.,Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Ann Cantrell
- M. Louise Fitzpatrick College of Nursing, 16196Villanova University, Villanova, PA, USA
| | - Suzanne C Smeltzer
- M. Louise Fitzpatrick College of Nursing, 16196Villanova University, Villanova, PA, USA
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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: 176] [Impact Index Per Article: 58.7] [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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Abstract
Sickle cell disease (SCD) can lead to potentially devastating complications that occur secondary to vaso-occlusion. Current national clinical guidelines are largely based on expert opinion, resulting in significant variation of management. Provider awareness regarding emergency department (ED) management of vaso-occlusive crises (VOC) remains unknown. A 23-question assessment of VOC management was administered to all eligible ED providers at Riley Hospital for Children between September and November 2018. Univariate analyses were performed to evaluate responses between groups. Of 52 respondents comprised of ED staff attendings (27%), resident trainees (58%), and ED nurses (15%), the majority were not aware of SCD management guidelines being available. Approximately 54% of providers endorsed a high comfort level in managing VOC, with staff and nurses more likely to report this than trainees (P=0.02). Less than 10% of all providers knew the recommended timeframe from triage to initial medication administration. Prolonged time between pain assessments was reported by 25% of providers with a high comfort level in managing VOC, which was similar to providers with a lower comfort level (13%, P=0.217). Only one fourth of all respondents appropriately did not use vital signs as an indication of a patient's pain level, and >10% reported not utilizing patient-reported pain scores. This was not significantly different between provider comfort levels (P=0.285 and 0.412, relatively). Our results suggest education regarding recommended practices was inadequate regardless of reported provider comfort. Further provider education and/or standardized ED VOC management guidelines may serve as areas for improvement in SCD care.
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Rushton S, Murray D, Talley C, Boyd S, Eason K, Earls M, Tanabe P. Implementation of an Emergency Department Screening and Care Management Referral Process for Patients With Sickle Cell Disease. Prof Case Manag 2020; 24:240-248. [PMID: 31369486 DOI: 10.1097/ncm.0000000000000356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF STUDY The purpose of the project was to describe the implementation and evaluation of a care management referral program from emergency departments (EDs) to care management services for patients with sickle cell disease (SCD). PRIMARY PRACTICE SETTING Patients were referred to Community Care of North Carolina (CCNC), which is a private-public collaboration providing care management services and served as a referral hub for the program. Patients received follow-up from either CCNC or the North Carolina Sickle Cell Syndrome Program. METHODOLOGY AND SAMPLE A multidisciplinary, multiorganizational group streamlined the referral process for patients with SCD who have ongoing care needs by linking patients from the ED to care management services. The article presents a review of program implementation and evaluation over a 3½-year period. The target population were patients who had a diagnosis of SCD and presented to the ED for treatment. Emergency department staff used a modified version of the Emergency Department Sickle Cell Needs Assessment of Needs and Strengths tool to screen for social behavioral health needs in areas such as emotional, financial, pain management, and resources. All forms were faxed to a central number at CCNC for follow-up care management services. Community Care of North Carolina then linked the patient with the appropriate agency and staff for follow-up. RESULTS More than 900 referrals were received in 3½ years. Pain was the most common reason for referral. An increase in care management intensity was observed over time. All levels of care management intensity saw an increase in the number of patients. IMPLICATIONS FOR CASE MANAGEMENT Care management occurred across organizations after careful planning among stakeholders. The interagency cooperation permitted the development of a streamlined process. In particular, the creation of a single point for referral was an important component to allow for population-level monitoring and ease of making referrals. Patients with ongoing care needs were identified and there was an increase in the intensity of outpatient care management services delivered.
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Affiliation(s)
- Sharron Rushton
- Sharron Rushton, DNP, MS, RN, CCM, CNE, is an assistant clinical professor of nursing at Duke University School of Nursing. She serves as faculty leader for the Population Care Coordinator Program and is experienced in care coordination. Scholarly interests include collaborations, interprofessional education, population health, and care coordination for biologically and socially vulnerable populations. Debbie Murray, RN, CMAC, CHC, CPN, CNM, is the director of Population Health Outreach and Care Coordination Services at CCNC. Her team of health educators and health coaches works to make sure that all patients have the access to appropriate care and the resources needed to improve self-management of their health concerns. Charles Talley, BS, is a health educator in Population Health Outreach and Care Coordination Services at CCNC. He maintains the sickle cell referral database and contacts patients following their visit to the ED to ensure that they have access to appropriate care and the resources needed to improve self-management of their health concerns. Sandra Boyd, MA, is the NC Sickle Cell Syndrome Program supervisor. Her team of educator counselors provides counseling, care coordination, and education to individuals with sickle cell disease and their families throughout the life course. Sandra works with her team to ensure that patients with sickle cell disease who visit an emergency department are contacted within 3 days of receipt of a referral by a CCNC care manager. The program's goal is to ensure that each client has a plan of care, is connected with a primary care provider and hematologist, and is linked to resources necessary that help improve his or her quality of life. Kern Eason, MBA, is the pediatric program manager at Community Care of North Carolina. He oversees CCNC Pediatric Program activities, particularly in coordination of CCNC's systems, practice, and patient-facing work on behalf of patients with sickle cell disease. Kern has specific skills in pediatric information technology and sees this as a key driver of quality in pediatric health care. Marian Earls, MD, MTS, FAAP, is the director of Pediatric Programs and deputy chief medical officer for Community Care of North Carolina and has led the CCNC Sickle Cell Project since 2013. She is board-certified in both General and Developmental & Behavioral Pediatrics. She is a clinical professor of pediatrics for the University of North Carolina Medical School. Paula Tanabe, PhD, MSN, MPH, RN, FAEN, FAAN, is a professor in the Schools of Nursing (SON) and Medicine at Duke University. Dr. Tanabe is the associate dean for Faculty Development and Data Science, SON. Her program of research is focused on improving systems of care, health outcomes, and quality of life for individuals with sickle cell disease
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Improving the Care of Individuals With Sickle Cell Disease in the Emergency Department Using a Quality Improvement Framework. Adv Emerg Nurs J 2019; 41:261-270. [DOI: 10.1097/tme.0000000000000256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Identifying Social-Behavioral Health Needs of Adults with Sickle Cell Disease in the Emergency Department. J Emerg Nurs 2017; 43:444-450. [DOI: 10.1016/j.jen.2017.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/29/2017] [Accepted: 04/08/2017] [Indexed: 11/17/2022]
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Powell RE, Lovett PB, Crawford A, McAna J, Axelrod D, Ward L, Pulte D. A Multidisciplinary Approach to Impact Acute Care Utilization in Sickle Cell Disease. Am J Med Qual 2017; 33:127-131. [PMID: 28460533 DOI: 10.1177/1062860617707262] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Sickle cell disease (SCD), an inherited red blood cell disorder, is characterized by anemia, end-organ damage, unpredictable episodes of pain, and early mortality. Emergency department (ED) visits and hospitalizations are frequent, leading to increased burden on patients and increased health care costs. This study assessed the effects of a multidisciplinary care team intervention on acute care utilization among adults with SCD. The multidisciplinary care team intervention included monthly team meetings and development of individualized care plans. Individualized care plans included targeted pain management plans for management of uncomplicated pain crisis. Following implementation of the multidisciplinary care team intervention, a significant decrease in ED utilization was identified among those individuals with a history of high ED utilization. Findings highlight the potential strength of multidisciplinary interventions and suggest that targeting interventions toward high-utilizing subpopulations may offer the greatest impact.
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Affiliation(s)
| | | | | | - John McAna
- 1 Thomas Jefferson University, Philadelphia, PA
| | | | | | - Dianne Pulte
- 3 German Cancer Research Center (DKFZ), Heidelberg, Germany
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Simpson GG, Hahn HR, Powel AA, Leverence RR, Morris LA, Thompson LG, Zumberg MS, Borde DJ, Tyndall JA, Shuster JJ, Yealy DM, Allen BR. A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers. West J Emerg Med 2017; 18:335-339. [PMID: 28435481 PMCID: PMC5391880 DOI: 10.5811/westjem.2016.11.32273] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/04/2016] [Accepted: 11/14/2016] [Indexed: 11/15/2022] Open
Abstract
Introduction A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the healthcare needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily. Methods We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (seven months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included patient-specific best practice advisories (BPA); an ED management protocol; and formation of a “medical home” for these patients. Results For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods we found the following: ED visits decreased by 16.5 visits/pt-yr (95% confidence interval [CI] [−1.32–34.2]); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI [−82.9–313.5]); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI [−1.73–10.1]); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI [−74.9–146.7]); and visits where the patient left before treatment were reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects, and no patient required admission to the intensive care unit 72 hours following discharge. Conclusion This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.
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Affiliation(s)
- Grant G Simpson
- University of Florida, Department of Pharmacology, Gainesville, Florida.,University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Hallie R Hahn
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Alex A Powel
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Robert R Leverence
- University of Florida Health, Department of Medicine, Division of Hospital
| | - Linda A Morris
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Lara G Thompson
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Marc S Zumberg
- University of Florida, Department of Hematology/Oncology, Gainesville, Florida
| | - Deepa J Borde
- University of Florida Health, Department of Medicine, Division of Hospital.,University of Florida Health, Care One Clinic, Division of Hospital Medicine, Gainesville, Florida
| | - Joseph A Tyndall
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Jonathan J Shuster
- University of Florida Health, Department of Health Outcomes and Policy, Gainesville, Florida
| | - Donald M Yealy
- University of Pittsburgh and UPMC, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Brandon R Allen
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
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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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