scholarly journals Patient Controlled Analgesia for Adults with Sickle Cell Disease Awaiting Admission from the Emergency Department

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
Josue Santos ◽  
Sasia Jones ◽  
Daniel Wakefield ◽  
James Grady ◽  
Biree Andemariam
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Treatment Algorithm ◽  
Retrospective Chart Review ◽  
Cell Disease ◽  
Patient Controlled Analgesia ◽  
Analgesic Treatment ◽  
Pain Scores ◽  
Ed Visits

Background.A treatment algorithm for sickle cell disease (SCD) pain in adults presenting to a single emergency department (ED) was developed prioritizing initiation of patient controlled analgesia (PCA) for patients awaiting hospitalization.Objectives.Evaluate the proportion of ED visits in which PCA was started in the ED.Methods.A two-year retrospective chart review of consecutive SCD pain ED visits was undertaken. Data abstracted included PCA initiation, low versus high utilizer status, pain scores, bolus opioid number, treatment times, and length of hospitalization.Results.258 visits resulted in hospitalization. PCA was initiated in 230 (89%) visits of which 157 (68%) were initiated in the ED. Time to PCA initiation was longer when PCA was begun after hospitalization versus in the ED (8.6 versus 4.5 hours,p<0.001). ED PCA initiation was associated with fewer opioid boluses following decision to admit and less time without analgesic treatment (allp<0.05). Mean pain intensity (MPI) reduction did not differ between groups. Among visits where PCA was begun in the ED, low utilizers demonstrated greater MPI reduction than high utilizers (2.8 versus 2.0,p=0.04).Conclusions.ED PCA initiation for SCD-related pain is possible and associated with more timely analgesic delivery.

Emergency Department Management of Children with Sickle Cell Disease.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1660-1660
Author(s):  
Melissa J. Frei-Jones ◽  
Amy L. Baxter ◽  
Charles T. Quinn ◽  
George R. Buchanan
Keyword(s):  
Emergency Department ◽  
Steady State ◽  
Sickle Cell Disease ◽  
Hospital Admission ◽  
Sickle Cell ◽  
Admission Rate ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Cell Disease ◽  
Ed Visits

Abstract Vaso-occlusive crises (VOC) are a common cause of emergency department (ED) visits for children with sickle cell disease (SCD). To better understand our patient population and compare with reports from other centers, we sought to describe the presentation, management, and disposition of children with VOC at our center’s ED. We also aimed to identify predictors of hospital admission. We retrospectively reviewed hospital records of all patients with SCD, age 8–19 years, who presented to our urban pediatric ED in 2003 with a chief complaint of pain. We identified all subjects diagnosed with VOC and not another cause of pain. We obtained the following data for each: SCD genotype; duration of VOC and treatment prior to ED presentation; the nature of analgesia and use of intravenous fluids (IVF) in the ED; hemoglobin (Hgb) concentration; and disposition (admitted, discharged, discharged with subsequent ED visit for same crisis). Categorical variables were evaluated by the χ2 and Fisher exact tests and continuous variables by the t-test. Odds ratios (OR) and 95% confidence intervals (CI) were calculated where appropriate. In 2003, there were 320 ED visits for patients with SCD and pain. Among these, there were 279 diagnoses of VOC in 105 individual patients: 45 had one visit, 25 two visits, and 16 ≥5 visits. Mean number of visits per patient was 2.7; 23 (22%) patients accounted for 145 (55%) visits. Homozygous sickle cell anemia (Hgb SS) was present in 73/105 patients, accounting for 222 (79%) ED visits. Overall admission rate was 179/279 (64%), with 167/179 admitted on their first visit and 12 on their return visit. Subjects with Hgb SS accounted for 147/179 (82%) admissions. Among those discharged who later returned to the ED during the same VOC, the admission rate was 86% (5 returned in 24 hours, 5 in 48 hours, 3 in 72 hours, and one 4 days later). Pre-ED home opioid use was reported in 75% of visits and was associated with increased likelihood of discharge (OR 1.63, CI 0.94–2.84, p=0.082). Duration of VOC before presentation did not significantly affect admission rate and averaged 53.2 hours for admitted patients and 49.7 hours for those discharged (p=0.689). Patients who received IVF in the ED (219/279; 79%) were less likely to be admitted (31% vs 56%, p<0.001). Hgb concentration was increased in 61%, decreased in 36% and unchanged in 3% of patients from steady-state values and was not associated with admission. After receiving 2 doses of morphine, 31 patients were discharged from the ED, while only 5 patients were discharged after receiving 3 or 4 doses of morphine. A departmental VOC protocol was followed for 25.4% of patients, with no impact on admission rate (p=0.290). In this retrospective analysis of a large series of pediatric sickle cell ED visits, patients presented later in their VOC, and admission rate was higher than previously reported. A small proportion of older patients with SCD accounted for most ED visits and hospitalizations. Hgb variation from steady-state was neither clinically significant nor predictive of admission or discharge. In contrast to previous studies, receiving IVF in the ED was associated with a greater likelihood of discharge. Home opioids prior to ED presentation seemed to decrease hospital admission. Adherence to our center’s VOC protocol did not appear to influence disposition from the ED.

scholarly journals Impact of the COVID19 Pandemic on Admissions and Emergency Department Visits of Adults with Sickle Cell Disease

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 37-38
Author(s):  
Alice J. Cohen
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Medical Center ◽  
Cell Disease ◽  
Face To Face ◽  
Outpatient Visits ◽  
Pain Medications ◽  
Time Period ◽  
Ed Visits

Background: The most common complication of sickle cell disease (SCD) in adults is vaso-occlusive crisis that is characterized by severe pain. These events can often be managed at home with oral analgesics, but if the pain is not controlled or the patient develops other associated problems, they seek care in an emergency department (ED). In the ED, they receive initial treatment with pain medications and are assessed for other complications such as infection and acute chest syndrome. If an individual's pain is not controlled in a short period of time, the majority of these patients are admitted to the hospital for inpatient management or placed in an observation unit (OBs) for 6-47 hours. The COVID-19 pandemic affected the Greater Newark community starting in mid March with the majority of all inpatient admissions (Ads) being COVID related through the end of May. It has been observed both at our medical center and nationally that during this time period and even afterwards, the number of ED visits and Ads had significantly fallen. The reasons for this finding may include fear of contracting COVID infection at the hospital, regular telemedicine (TM) calls to facilitate outpatient management, and an increase in the number of prescriptions of home pain medications. The purpose of this analysis was to examine patterns of ED visits, Ads, outpatient visits, prescription renewals and nurse (RN) and social worker (MSW) calls in order to determine the impact of COVID-19 infection on the local SCD community. Methodology: A retrospective review was undertaken of billing data and the EMR of all patients with SCD treated at Newark Beth Israel Medical Center (a 450 bed community-based academic tertiary care medical center) between January 2020 and June 2020. Data collected included the number of and reason for ED and OBs, Ads, the number of TM and outpatient visits, and MSW and RN telephone contacts. All patients 18 years of age and older were included. Overall, 100 adults with SCD received care between January and June. Results: Peak hospital COVID Ads, ED and OBs for all patients (SCD and non-SCD) occurred during the weeks between March 25 and May 24, 2020 with a daily inpatient census over 200 between April 7 and 24. SCD Ads at peak COVID (April-May) were significantly lower at 26±2/month compared to 64±11/month pre-COVID (January-February) (p= 0.04). ED and OBs were unchanged. During the peak of COVID, 10/93 (11%) SCD Ads (1 death) were COVID related with 80/96 (86%) for uncomplicated pain crises. MSW and RN called all patients proactively to offer support at onset of COVID pandemic. During this same time period, the number of MSW telephone contacts increased from 138±37/month pre-COVID to 372±21/month during COVID (p=0.02). RN contacts with SCD patients were stable and mostly were for pain prescription renewals. TM was initiated in March 2020 and an increase in these visits correlated with a fall in face to face physician visits: 83.5±11/month pre-COVID to 39.5±8/month peak COVID (p= 0.04), and TM 0/month pre-COVID and 31±4/month peak COVID (0.01). Conclusion: The outbreak of COVID-19 in the community reduced the number of Ads for patients with SCD without an increase in ED and OBs visits. MD face-to-face encounters were reduced but outpatient care continued with the initiation of TM, regular RN contact with maintenance of pain medication prescriptions and a greater numbers of MSW calls for psychosocial support. Further investigation and understanding of the use of Ads for SCD care, and the reduction during COVID, may have implications for current SCD management. Disclosures Cohen: GBT: Speakers Bureau.

Health Care Utilization Patterns and Emergency Department Reliance During Transition of Care From Pediatric to Adult Providers In Sickle Cell Disease

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 83-83 ◽  
Author(s):  
Bradd G. Hemker ◽  
David C Brousseau ◽  
Ke Yan ◽  
Raymond G Hoffmann ◽  
Julie A. Panepinto
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Medical Home ◽  
Transition Period ◽  
Age Groups ◽  
Cell Disease ◽  
Outpatient Visits ◽  
Transition Group ◽  
Ed Visits

Abstract Abstract 83 Background: Improved survival of patients with sickle cell disease has led to increased attention on the transition of care from pediatric to adult providers. Recent studies have shown increased emergency department (ED) utilization as well as an increased risk of mortality during this transition period for patients with sickle cell disease. Suggested reasons for such changes include loss of a medical home, loss of insurance, and loss of access to outpatient clinics as pediatric sickle cell patients transition to adult services. Emergency Department Reliance (EDR), defined as the number of ED visits divided by the number of ED and outpatient visits, views ED visits in relation to all ambulatory visits. Those with more severe disease, who utilize the ED more, should also have more outpatient visits, while those without adequate outpatient clinic access simply use the ED more without a rise in outpatient clinic visits, thus increasing EDR. EDR, therefore, is used to differentiate increased ED use due to need for care from increased ED use as an access issue. We hypothesized that as patients transition from pediatric to adult centered care, loss of a primary medical home would lead to an increase in the EDR. Methods: We conducted a retrospective cohort study using the Wisconsin State Medicaid database from 2003–2007. This database includes 757 patients of any age with sickle cell disease who are part of the Wisconsin Medicaid system. Consistent with previous literature, having sickle cell disease was defined by having at least one inpatient hospitalization, or two outpatient visits at least one month apart, with a diagnosis of sickle cell disease. All encounters during the study period were extracted from the database and linked by unique anonymous identifiers. Information extracted included age, all diagnosis codes, and classification as ED visit, outpatient visit, or inpatient hospitalization. The study population was divided into three mutually exclusive age groups: 1) children: ≤ 18 years old for the entire study period, 2) the transition group who turned 19 years old during the study period; and 3) Young adults age ≥ 19–45 years at first encounter. Adults age 3 46 at first encounter were eliminated from the analysis as the goal was to compare the transition group to the age groups immediately above and below. The median Emergency Department Reliance (ED visits/[ED + outpatient visits]) was compared for each age group for sickle cell related diagnoses, all diagnoses, and sickle cell crisis diagnoses using non-parametric, multiple-comparisons adjusted tests. Results: The 687 remaining patients had a total of 32,258 ambulatory visits over the five year study period, including 20,418 outpatient visits and 11,840 emergency department visits. There were 345 children, 65 patients in the transition group, and 277 young adults. For sickle cell diagnoses, the transition group had a significantly higher EDR than children (0.50 vs. 0.39, p=0.031) and a higher EDR than young adults, though this increase failed to achieve statistical significance (0.50 vs. 0.41, p=0.360). The difference in EDR between the children and adults for sickle cell diagnoses was not significant. A similar pattern emerged when computing EDR based on all diagnoses, with the EDR for the transition group being significantly higher than for children (0.35 vs. 0.28, p<0.001) as well as increased compared to adults, although this did not reach statistical significance (0.35 vs. 0.31, p=0.073). Lastly, the EDR was highest in all age groups for sickle cell crisis diagnoses (EDR ≥ 0.68 in all three groups). Conclusions: Patients with sickle cell disease who are transitioning from pediatric to adult centered care have an increased reliance on the emergency department as a location of care for sickle cell diagnoses. As adults, emergency department reliance returns to similar levels as childhood, suggesting a stabilization of a medical home following the transition period. The EDR is highest for all groups at times of acute pain crisis related to sickle cell disease, consistent with the need for emergent care in those situations. These findings support the hypothesis that increased ED utilization during the transition period from pediatric to adult providers is potentially due to limitations in access to care. Disclosures: No relevant conflicts of interest to declare.

Age-Related Emergency Department Reliance and Healthcare Resource Utilization in Patients with Sickle Cell Disease

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 475-475
Author(s):  
Morey A. Blinder ◽  
Francis Vekeman ◽  
Medha Sasane ◽  
Alex Trahey ◽  
Carole Paley ◽  
...  
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Healthcare Costs ◽  
Research Funding ◽  
Transition Period ◽  
Cell Disease ◽  
Adult Care ◽  
Age Related ◽  
Ed Visits

Abstract Abstract 475 Introduction: For sickle cell disease (SCD) patients (pts), inadequate care during pediatric to adult transition may result in increased emergency department (ED) utilization. Emergency department reliance (EDR: total ED visits/total ambulatory [outpatient + ED] visits) identifies the proportion of ED visits in relation to all ambulatory visits and differentiates between acute episodic ED users from those who may not have adequate access to outpatient care. The aim of this study is to investigate age-related patterns of EDR and associated healthcare costs in pediatric SCD pts and those transitioning from pediatric to adult care. Methods: State Medicaid data from FL (1998–2009), NJ (1996–2009), MO (1997–2010), IA (1998–2010), and KS (2001–2009) were used for this study. Pts with ≥2 SCD diagnoses (ICD-9 282.6x) and ≥1 blood transfusion were included in the analysis. Pts were followed for as long as they were enrolled in Medicaid. Quarterly rates of outpatient visits, ED visits, EDR, SCD complications associated with ED visits, and ED visits resulting in hospitalization were evaluated. Total healthcare costs were calculated and stratified by outpatient (OP), inpatient (IP), ED, and prescription drug (Rx). SCD complications included pain, stroke, leg ulcers, avascular necrosis, infections, as well as pulmonary, renal, and cardiovascular events. Based on published thresholds, high EDR was defined as >0.33. A logistic regression model was used to assess associations between high EDR and transition age (<18 vs. ≥18 years [yrs]), transfusions, hydroxyurea use, and SCD complications. Other covariates included transfusions during the previous quarter, other relevant medications (e.g.: pain medication, diuretics, anticoagulants), comorbidities (e.g.: hypertension, myocardial infarction, liver disease), and, serving as proxies for overall health status, the frequency of OP, IP, and ED visits during the previous quarter. Regressions analyses were also used to calculate adjusted costs differences between pts with high vs. low EDR. Findings: A total of 3,208 pts were included (FL: 1,550, NJ: 992, MO: 489, KS: 121, IA: 56) in the study. Each pt was observed for an average (SD) of 6.0 (3.1) yrs. Average ED visits/quarter increased from 0.76 to 2.29 between age 15 and 24, reaching a peak of 2.9 at age 36 (Figure 1). Regardless of age, the most common SCD complications associated with ED visits were pain, infection, and pneumonia. Beginning at age 15, EDR rose from 0.17 to reach 0.29 at age 22, and remained high throughout adulthood. The quarterly rate of ED visits resulting in hospitalizations followed a similar pattern. Regression analysis indicated that pts were more likely to have high EDR during the post-transition period (≥18 yrs old, odds ratio [OR]: 2.38, p<0.001) and when experiencing an SCD complication (OR: 4.18, p<0.001). Pts with high EDR incurred statistically significantly higher inpatient and ED costs, resulting in significantly higher total costs (high vs. low EDR, unadjusted costs difference, OP: -$441, p<.001; IP: $7,427, p<.001; ED: $442, p<.001; Rx: -$447, p=0.182; total: $7,376, p<.001 [Table 1]; adjusted costs difference, OP: -$285; IP: $3,485; ED: $120; Rx: -$91; total: $3,086, p<.001 for all). Conclusion: Compared to children, pts transitioning to adulthood relied more on ED for their care. Moreover, pts with high EDR incurred more frequent hospitalizations and significantly higher healthcare costs, highlighting the need to improve transition related support including better access to primary care and increased engagement with SCD patients. Disclosures: Blinder: Novartis Pharmaceuticals: Consultancy, Research Funding. Vekeman:Novartis Pharmaceuticals: Research Funding. Sasane:Novartis Pharmaceuticals: Employment. Trahey:Novartis Pharmaceuticals: Research Funding. Paley:Novartis Pharmaceuticals: Employment. Magestro:Novartis Pharmaceuticals: Employment. Duh:Novartis Pharmaceuticals: Research Funding.

Episodic Patterns of High Emergency Department Utilization Among Sickle Cell Disease Patients

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 316-316
Author(s):  
Susan Paulukonis ◽  
Lisa Feuchtbaum ◽  
Elliott Vichinsky ◽  
Mary Hulihan
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Surveillance System ◽  
Research Funding ◽  
Cell Disease ◽  
Ed Visits ◽  
High Utilization ◽  
The Mean ◽  
Over Time

Abstract Background: High utilization of emergency department (ED) services among those with sickle cell disease (SCD) compared to the general population and compared to those with other chronic diseases is well documented in the literature. Some reports note that high utilization is episodic. Most analyses address the problem as a consistent one within patients, rather than consistent over time across the patient population but sporadic for patients. Reducing the high rate of ED utilization among patients with SCD requires an understanding of temporal patterns of ED utilization, the consistency of ED utilization over time by patients and the proportion of the population affected at any given time. Methods: CDC has developed the Sickle Cell Data Collection program (SCDC) to conduct state level surveillance in this disease, and to continue and improve upon work begun through the Registry and Surveillance System in Hemoglobinopathies (RuSH). Through SCDC, California has collected ED and hospitalization data for years 2005-2014 on 4,325 people with SCD. A period of high ED utilization among this cohort was defined as three or more ED encounters (either treat and release or admission to the hospital from the ED) for any diagnosis (not only SCD diagnoses) each fewer than 30 days from the prior visit. The start of an episode of high utilization is the date of the first ED encounter; the end is the date of the last eligible ED encounter. All cohort members were divided into categories of utilization using the proportion of time spent in periods of high utilization divided by the total time in cohort. Total time is cohort is defined as the length of time from the earliest appearance in the ED or hospital data 2005-2014 to the latest appearance. The five categories were defined as no episodes of high ED utilization, and approximate quartile groups for those with high ED utilization: 1.1 to 3.0%, 3.1-10.0%, 10.1% or greater. Age categories (pediatric is < 21 years, and adult is 21 years or older) are defined as patient age at close of study (end of 2014) or at death if prior. Patient ID beginning with P is a pediatric, A is adult in the figures. Results: There were 4,325 individuals with 27,694 person years in the cohort (mean 6.4 person years, median 7.6 person years). Sixty-three percent (n=2,715) of the cohort were aged 21 years and older. Forty-five percent, (n=1,955, 513 pediatric and 1,442 adults) had at least one episode of high utilization during the 10 year study for a total of 7,866 episodes of high utilization. Forty-three percent of patients with one or more high utilization episodes were male, and 63% were between the ages of 20 and 50. Nine percent of these high utilizing patients' total time in the cohort was made up of episodes of high utilization. The mean time span from start of episodes of high utilization to end of the episodes was 63.3 days, median 35 days; mean number of ED visits per episode was 9.0, median 4.0. Most episodes of high utilization were brief: 42.2% included just three visits, and 70.7% included five or fewer ED visits. Among these individuals with episodes of high utilization, the mean number of such episodes was 4.0 over the 10 years study period, and the median was 2.0. Most (76.4%) had five or fewer high utilization episodes, and 35.5% had just one (n = 693). Sample utilization patterns, including hospital admissions, are shown in Figure 1. Conclusions: We demonstrate that among individuals with SCD seen in a population-based, statewide surveillance system, periods of high ED utilization are common, but most SCD patients have only a limited number of short episodes of such utilization. We found that high ED utilization is episodic rather than consistent within individuals, and that while the range of time spent in episodes of high utilization varies, few patients are high utilizers of ED services over a long period of time. Statewide surveillance that follows individual patients over time and in different hospital settings and includes ED utilization (including visits not coded as being related to SCD), provides high quality public health information to inform clinicians and healthcare systems in their development of efforts to reduce ED utilization among those living with SCD. Figure 1 Figure 1. Disclosures Paulukonis: Pfizer: Research Funding; Biogen: Research Funding.

scholarly journals Characteristics and Trends of Sickle Cell Disease Patients Once Presented to the Emergency Department, Reflecting on a Possible Burden: United States (2010-2015)

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4845-4845
Author(s):  
Tarek Haykal ◽  
Ragheed Al-Dulaimi ◽  
Josiane Kerbage ◽  
Varun Samji ◽  
Sowmya Goranta ◽  
...  
Keyword(s):  
United States ◽  
Emergency Department ◽  
Sickle Cell Disease ◽  
Life Expectancy ◽  
Medical Care ◽  
Sickle Cell ◽  
National Database ◽  
Cell Disease ◽  
The Us ◽  
Ed Visits

Background: Sickle cell disease (SCD) is an autosomal recessive, multisystem disorder, characterized by chronic hemolytic anemia, painful episodes of vaso-occlusion, progressive organ failure and a reduced life expectancy. SCD is the most common monogenetic disease, with millions affected worldwide. It is estimated that there are 100,000 people living with SCD in the United States (US). Patients with SCD often use emergency department (ED) services to obtain medical care. Limited nationwide information in the recent years is available about ED use among patients with SCD. Methods: Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2010-2015 were analyzed, to examine the prevalence and care of SCD patients in the EDs across the US. The NHAMCS is a survey of hospital ED and outpatient visits. Cases were identified using ICD 9 codes and all analyses accounted for complex survey structure of the data. Results: On average, approximately 1.4 million ED visits were estimated to have occurred between the years 2010 and 2015 with SCD as one of the diagnoses listed, where 860,000 were attributed to sickle cell crises. 37.29% were of female sex while 62.71% were males. 11.62% were under 15 years of age, 28.22% were between 15 and 24 years of age, 51.15% were between the ages of 25 and 44 years and 9.02% were older than 45 years. The chief complaint for the majority of cases was pain. The expected source of payment were Medicare and Medicaid at 30.45% and 41.98% respectively, while private insurance coverage and self-pay were only at 11.71% and 5.81% respectively. Of all SCD ED visits, 68.5% were considered as initial presentations and up to 23.37% were considered as follow-up. 33.31% of the visits ended up needing a hospital admission while 66.69% got discharged from the ED.In 43.39% of the visits, a form of imaging was ordered, compared to 56.61% where it was not. Upon getting triaged in the ED, 67.62% of all SCD visits needed either emergent or urgent medical attention, while the rest were either none-urgent, or a regular check-up. Conclusion: In well-resourced countries, like the US, comprehensive care programs have increased life expectancy of sickle cell disease patients, with almost all infants surviving into adulthood. However unfortunately with poor control of the disease due to limited therapeutic options and with growing morbidity for the aging SCD patients, the burden on the medical system becomes extremely high. Our study highlights the significant burden SCD creates in the EDs across the US based on data collected from a national database. Disclosures No relevant conflicts of interest to declare.

The First National Level Estimate of Emergency Department Charges for Sickle Cell Disease.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 553-553
Author(s):  
Sophie Lanzkron ◽  
Carlton Haywood
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Patient Population ◽  
Conflicts Of Interest ◽  
National Level ◽  
Cell Disease ◽  
Sampling Weights ◽  
The Us ◽  
Ed Visits

Abstract Abstract 553 First National Level Estimate of Emergency Department Charges for Sickle Cell Disease It is estimated that there are 100,000 people with sickle cell disease (SCD) living in the US. Little data is currently availabel on the number of emergency room visits made per year by this patient population. Given prior data demonstrating the cost savings associated with comprehensive care delivery and specialized day hospital units that have decreased ED visits and hospitalizations, our goal was to estimate the national burden of SCD care in the ED setting. The purpose of this study was to estimate the number of ED visits made by SCD patients in 2006, the total and average charges for those visits and the subsequent hospital admissions, and to identify factors that predicted if patients were admitted to the hospital. In addition, we used the online Healthcare Cost and Utilization Project program (HCUP) to compare the number of SCD visits with the number of ED visits and subsequent admissions for other chronic illnesses. Methods: The Nationwide Emergency Department Sample (NEDS) contains information from 950 hospitals and approximates a 20% stratified sample of US hospital based EDs. Data is currently only availabel for 2006. Using this dataset we identified all ED visits with the following SCD ICD9 codes 28260,28261,28262,28263,28264,28268,28269,28241,28242 listed anywhere in the diagnosis list. Bivariate and multivariate analyses were conducted using t-tests, oneway ANOVAs, and multiple linear or logisitic regressions as appropriate. Sampling weights are included in the NEDS to allow for the generation of national estimates. In addition to the full NEDS dataset the Agency for Healthcare Research and Quality makes availabel on-line a query system based on HCUP data free on its website. We used this system to collect data on total ED visits for asthma, HIV and congestive heart failure (CHF) that ended in a hospital admission using the clinical classification software codes 128, 5, and 108 as defined in the HCUP system. Results: There were a total of 58993 ED visits for patients with SCD sampled in the NEDS in 2006, representing a national estimate of 232,381 ED visits. Using the weighted data there were an estimated 190,000 adult ED visits and 44,000 pediatric visits. The total charges for all of the ED visits were estimated to be $266 million of which 191 million were for patients not subsequently admitted to the hospital. Being female and adult resulted in significantly higher ED charges. 50% of the visits were covered by Medicaid, 22% by Medicare, 18% were private pay, 7.5% self-pay and the remainder were no charge or other. 60% of the visits occurred in the South, 18% in the Northeast, 15% in the Midwest and 7% in the West. 5% of the visits had a code for pneumonia, 0.25% had a code for stroke and 7.3% had a code for asthma. These ED visits resulted in an estimated 91,000 hospitalizations. Pediatric patients were more likely to be admitted than adult patients (44% v 38% p=0.03). The combined ED and inpatient charges for those admitted were estimated to be $2.7 billion with a mean charge of $23,669 (range $591-871,111). 64 individuals are estimated to have died in the ED and another 522 died during their hospital stay. The average age of those that died in the ED was 33 and in the hospital was 42. In adjusted analyses being female, in the pediatric age group, or having a code for sickle crisis, asthma, stroke or pneumonia all were associated with a significant increase in odds of being admitted to the hospital. Table 1 shows the comparison number of admissions from the ED for SCD, asthma, HIV and CHF. Conclusions: Given the size of the US sickle population this data suggests that the ED is a major source of care for this patient population. Given that there are over 2 billion dollars in charges for those admitted from the ED, a focus of improving quality of care and decreasing costs of care should be eliminating ED use by the SCD population by providing alternative venues for treatment of painful crises that is more likely to result in a discharge home. Disclosures: No relevant conflicts of interest to declare.

Reduction in the Frequency of Emergency Department Visits for Complications Related to Sickle Hemoglobinopathies: Effects of Aggressive Hydroxyurea Therapy

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 2067-2067 ◽  
Author(s):  
Ashok Raj ◽  
Arun Ranjan Panigrahi ◽  
Scott N. Myers ◽  
Jennifer Mullinax ◽  
John A Myers ◽  
...  
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Expert Panel ◽  
Treatment Protocol ◽  
Emergency Department Visits ◽  
Cell Disease ◽  
Hb S ◽  
Ed Visits ◽  
Hydroxyurea Therapy

Abstract Context Early and aggressive use of hydroxyurea (HU) in sickle hemoglobinopathies has been in practice at our comprehensive sickle cell center since 2012 when standardized protocols were still evolving. The consensus treatment protocol for hydroxyurea therapy in sickle cell disease (SCD) documented in the "Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014" has authenticated our clinical practice. Objectives Although emergency departments play an important role in providing acute and urgent care for patients with SCD, the frequency of visits by patients can possibly be reduced by increased use of sickle-directed therapies in the outpatient setting. The objective of this study was to determine the impact of aggressive HU therapy, including shared decision making with parents for early use of HU and dose escalation up to the maximum tolerated dose, on the frequency of emergency department (ED) visits for patients with sickle hemoglobinopathies. Methods ED visits by patients with sickle hemoglobinopathies (HbSS disease, Hb S beta zero thalassemia, HbSC disease, Hb S beta plus thalassemia) were identified using ICD-9-CM diagnosis codes of 282.6, 282.60, 282.61, 282.62, 282.63, 282.64, 282.68, 282.69, 282.41, and 282.42. From visits having one or more of these diagnoses, cases that had indicated that the visit was related to an injury, poisoning, or adverse effect of medical treatment were excluded to form the study group of emergency department visits by patients. However, if the ED visit was for HU complications/side effects, they were included. Data from 2010-2015 was collected from the ED of Kosair Children's Hospital and affiliated hospitals in Louisville, which are the community-wide and primary locations where pediatric patients with sickle hemoglobinopathies are evaluated for disease-related complications requiring emergency management including pain crises, fever episodes, acute chest syndrome, etc. To determine if aggressive use of HU was associated with adecrease in the frequency of ED visits, segmented linear regression techniques were used to compare the mean monthly rates of ED visits before and after implementation of this treatment strategy. Results: The rate of sickle hemoglobinopathies seen in the ED significantly decreased after implementation of the aggressive HU treatment protocol (β=2.48 vs. β=-3.91, p=0.003). After implementation of the aggressive HU protocol, there has been a 55% decrease in the monthly rate of sickle hemoglobinopathies seen in the ED (21.0 vs. 9.5, p<0.001) from the peak monthly rate seen in 2012, which is a 40% reduction since the start of the study period [15.8 vs. 9.5, p=0.011]). Conclusion: Substantial reduction in the frequency of ED visits occurred in children with sickle hemoglobinopathies with the simple intervention of early and aggressive usage of HU and its dose escalation to the maximally tolerated dose. The findings of this study suggest that improving the process of prescribing HU as outlined in the "Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014" reduced the complications of sickle hemoglobinopathies requiring emergency care management and is an indicator of the enhanced quality of health care in sickle hemoglobinopathies. Figure 1. The average monthly rate of sickle hemoglobinopathies seen in the ED stratified by year. --- = reference point in which aggressive HU was implemented. Figure 1. The average monthly rate of sickle hemoglobinopathies seen in the ED stratified by year. --- = reference point in which aggressive HU was implemented. Disclosures No relevant conflicts of interest to declare.

scholarly journals Evaluation of Vaso-occlusive Crisis Management With Patient-Controlled Analgesia in Children With Sickle Cell Disease Requiring Hospitalization

2021 ◽  
Vol 26 (6) ◽  
pp. 615-623
Author(s):  
Claire Arbitre ◽  
Yves Pastore ◽  
Benoit Bailey ◽  
Niina Kleiber ◽  
Nancy Robitaille ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Pediatric Patients ◽  
Acute Chest Syndrome ◽  
Cell Disease ◽  
Patient Controlled Analgesia ◽  
Pain Scores ◽  
A Prospective Study ◽  
Reduced Time ◽  
Median Pain

OBJECTIVE The aim of this study was to review the use of patient-controlled analgesia (PCA) in sickle cell disease (SCD) for pediatric patients with vaso-occlusive crisis (VOC) in our institution and to compare the effect of early vs late PCA start on pain relief and LOS. METHODS This retrospective study included all pediatric patients treated with PCA for a severe VOC from 2010 to 2016. “Early-PCA” was defined as start of PCA within 48 hours of arrival. Time to reach adequate analgesia was defined as the time to reach 2 consecutive pain scores less than 5/10 at 4-hour interval. RESULTS During the study period, 46 patients presented 87 episodes of VOC treated with PCA. Sixty-three patients with VOC were treated with Early-PCA and 24 with Late-PCA. Both groups were comparable except for median pain score at admission; the Early-PCA group had higher scores: 9.0/10 vs 7.0/10. Time to reach adequate analgesia could be evaluated only in a subset of patients (n = 32) but was shorter in the Early-PCA group with a median difference of 41.0 hours (95% CI −82.0 to −6.0). Early-PCA was associated with a median reduction in LOS of 3.4 days (95% CI −4.9 to −1.9). There was no difference between the 2 groups in terms of side effects and occurrence of acute chest syndrome during hospitalization. CONCLUSIONS In this study, a reduced time to reach adequate analgesia and LOS was noted in the Early-PCA group for severe VOC. A prospective study is required to confirm these results.

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