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

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

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

Continuity of Care for Acute Visits In Sickle Cell Disease: Do Patients Go to More Than One Site?

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 735-735
Author(s):  
Julie A. Panepinto ◽  
Pamela L Owens ◽  
Andrew Mosso ◽  
Claudia A Steiner ◽  
David C Brousseau
Keyword(s):  
Emergency Department ◽  
Quality Of Care ◽  
Sickle Cell Disease ◽  
Acute Care ◽  
Sickle Cell ◽  
Private Insurance ◽  
Cell Disease ◽  
Public Insurance ◽  
Number Of Visits

Abstract Abstract 735 Sickle cell disease is characterized by frequent and recurrent vaso-occlusive events that often require multiple acute care visits to the emergency department (ED) or hospital. Multiple visits for sickle cell disease are more common among younger adults and those with public insurance than children and older adults and those with private insurance or who are uninsured.1 It is not known, however, whether these multiple visits are made to more than one site of care which could potentially reduce the patient's quality of care. The objective of this study was to examine the continuity of acute care visits for patients with sickle cell disease, as defined by having one site of care (versus multiple sites of care). We hypothesized that children with sickle cell disease and those sickle cell disease patients with private insurance would be more likely to use one ED or hospital for their acute care, while adults with sickle cell disease and those sickle cell disease patients with public insurance would be more likely to use multiple sites of care. We conducted a retrospective cohort study using 2005 and 2006 data from the Healthcare and Cost Utilization Project State Inpatient Databases and State Emergency Department Databases. Data from eight states (AZ, CA, FL, MA, MO, NY, SC, and TN) with an encrypted patient identifier were used to examine all acute care visits for sickle cell-related diagnoses in children and adults with sickle cell disease. Our primary outcome was the proportion of patients with all acute care visits to one site. We derived a logistic regression model to examine the association between age and primary expected payer and likelihood of having a single site of care, adjusting for rurality of the patient's residence, gender, number of visits and state of residence. A total of 21,118 patients with sickle cell disease had one or more sickle cell disease -related acute care visits to the ED or hospital. There were 13,533 patients who made two or more visits. Approximately 66% of these patients (n=8,895) had public insurance as the primary expected payer. Of the 5,030 children (ages 1–17 years) with multiple visits, 77.3% went to the same site for their acute care over the two year time period. This is in contrast to the adults (n=8,503) for whom only 51.3% received all acute care at the same site. The proportion of patients who went to one site of care decreased as the number of visits made increased for both children and adults. In multivariable analyses, adolescents (10- 17 years olds) were more likely than young adults (18-30 years old) to go to one site for all acute care (adjusted odds ratio (AOR) 3.78, 95% confidence interval (CI) 3.23–4.43). Analyzing the likelihood of going to one site for all acute care by primary expected payer, uninsured patients were less likely to have one site of care compared to patients with private insurance as the expected payer, even after controlling for the number of visits. This association was especially pronounced among patients with an increased number of visits during the two year study period. When examining adults who made four acute care visits, 41.2% of those without insurance went to one site for care compared to 56.4% with private insurance and 56.5% with public insurance. In children with 4 acute care visits, 54.5% of those without insurance went to one site compared to 78.7% with private insurance and 75.2% of those with public insurance. In multivariable analysis, having public insurance and being uninsured were associated with decreased likelihoods of going to one site for all acute care (AOR 0.85, 95% CI 0.77–0.93 and AOR 0.64, 95% CI 0.55–0.74 respectively) compared to having private insurance. Young adults and patients who are uninsured or who have public insurance are more likely to go to multiple sites for their acute care compared with children and those with private insurance. Although the long-term effects of having multiple sites of acute care are unknown, it may indicate a lack of a medical home and may contribute to lower quality of care. 1. Brousseau DC, Owens PL, Mosso AL, Panepinto JA, Steiner CA. Acute Care Utilization and Rehospitalizations for Sickle Cell Disease. JAMA 2010;303(13):1288-1294. Disclosures: No relevant conflicts of interest to declare.

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

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

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

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

Comparison of Emergency Department Wait Times in Adults with Sickle Cell Disease Versus Other Painful Etiologies

Hemoglobin ◽  
2016 ◽  
Vol 40 (5) ◽  
pp. 330-334 ◽  
Author(s):  
Dianne Pulte ◽  
Paris B. Lovett ◽  
David Axelrod ◽  
Albert Crawford ◽  
John McAna ◽  
...  
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Wait Times ◽  
Cell Disease ◽  
Emergency Department Wait Times

scholarly journals Managing Sickle Cell Disease Patients with Acute Pain Crisis in the Most Appropriate Setting

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 2169-2169
Author(s):  
Michel Gowhari ◽  
Tiesa Hughes-Dillard ◽  
Catherine Ryan ◽  
Alexia Johnson
Keyword(s):  
Sickle Cell Disease ◽  
Acute Care ◽  
Sickle Cell ◽  
Acute Pain ◽  
Admission Rate ◽  
Cell Disease ◽  
Observation Unit ◽  
Improvement Project ◽  
Hospital Admission Rate ◽  
Pain Crisis

Introduction: Pain is the top concern of individuals with sickle cell disease (SCD). Acute painful vaso-occlusive episodes in SCD are the leading cause of emergency department (ED) encounters and frequent hospital admissions. Well-documented disparities include significant delay and under treatment of SCD patients with acute pain crisis in the ED. An acute care observation unit (ACOU) staffed with SCD specialists can help to address these disparities. SCD patients treated in a dedicated ACOU have a 40% lower admission rate than patients treated in the ED. An expedited transfer and treatment program at our dedicated sickle ACOU at the University of Illinois Hospital (UIH) was implemented with the goal of improving overall care and decreasing the hospital admission rate for SCD patients. Method: This is an outcome study of individuals with SCD >16 years of age who presented with an acute painful episode to UIH. A quality improvement project used the Plan-Do-Study-Act translation method. The following key areas were identified for intervention: 1) established criteria for direct ACOU admission, 2) expedited transfer to the ACOU from the ED, 3) addition of a third provider to expand hours, and 4) establishing a consistent but individualized pain treatment plan across the ED and ACOU. The number of admissions to hospital of patients with SCD was examined from September 2018 through August 2019. Applying the Donabedian triad of Structure, Process, and Outcomes, we demonstrated improved outcome and decrease hospitalization. Results: There were 877 admissions to the ACOU from January to July of 2019, which is an increase of 37% compared to the same period in 2018. Of the 877 admissions, 793 were discharged home (90.4%) as compared to 88.6 % in 2018. The average time to first dose of opioids in the ACOU in 2019 was 55 minutes with and average decrease in the pain score of 2.62 during an average length of stay of 4:18 hours. Conclusions: Expedited care and treatment with a focus on improving quality and improving access resulted in increased volume of patients treated and decreased rate of admission to the hospital. Allocating resources to a dedicated sickle acute care observation unit can significantly decrease inpatient hospitalizations. Table. Disclosures No relevant conflicts of interest to declare.

Addressing challenges of clinical trials in acute pain: The Pain Management of Vaso-occlusive Crisis in Children and Young Adults with Sickle Cell Disease Study

2016 ◽  
Vol 13 (4) ◽  
pp. 409-416 ◽  
Author(s):  
Kerri A Nottage ◽  
Jane S Hankins ◽  
Lane G Faughnan ◽  
Dustin M James ◽  
Julie Richardson ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Young Adults ◽  
Pain Management ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Acute Pain ◽  
Cell Disease ◽  
Children And Young Adults ◽  
Disease Study

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

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

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

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