Time Is Quality of Life (QoL): An Institutional Review of Emergency Department Management of Acute Vaso-Occlusive Episodes in Patients with Sickle Cell Disease

Background:

Vaso-occlusive episodes (VOE) are the primary cause of morbidity in sickle cell disease (SCD) and adversely impact the quality of life of patients living with the disease (Osunkwo, Am J Hematol 2021). The management of acute pain in patients with SCD is a complex challenge in the emergency department (ED). The current guidelines on acute pain management in SCD from the American Society of Hematology (ASH) recommends the initial analgesic must be provided within an hour from arrival to the ED, with continued assessment for pain and analgesia every 60 minutes (Brandow et al, Blood Adv 2020). Previous work by our sickle cell team and infusion center nurses showed improvements in time to first dose with the institution of an Individualized pain plan (IPP), aligning the infusion center with the ASH guidelines in the ambulatory setting. Our institution has no available data regarding the average time for the first analgesic from ED presentation. This study aims to establish situational awareness of acute pain management in the ED for patients with SCD compared to the infusion center and the Sickle Cell Care Guidelines, as outlined in the 2020 publication by ASH.

Methods:

This retrospective chart review includes all patients with SCD evaluated in the ED for an acute VOE from June 2022 to July 2023. Time to first dose of analgesic in the ED is defined as the time from registration to the time of first opioid dose (either IV or oral); in the infusion center, time to first dose is based on time of check-in to the clinic until the time of first opioid dose. The variables of interest include the time for initial triage, the time for the initial dose of analgesics, and the route of analgesic administration (oral vs. IV). Other variables that are included are age and sex and location of care, including Main Campus ED, infusion center, or regional hospital ED. Time to first analgesic was compared as an average of time difference at Main Campus, regional hospital ED, and infusion center. Time to first dose for age comparison was completed using average time to first dose between pediatric (<18 years) and adult (>18 years) patients.

Results:

Our cohort includes 42 patients representing 107 unique encounters to the infusion center (12) or the ED (95) with SCD with crisis (ICD-10: D57.00). ED visits include stays to the main campus ED and the regional hospitals. Patients who presented to their regular scheduled appointments in an acute VOE are not included in the analysis. Demographically, 24 (57%) patients are male, while 18 (43%) are female. One patient (2%) identifies as Hispanic, while the other 41 (98%) patients identify as black. The average time for the first analgesic dose for all patients in acute pain crisis at the main ED is 3:47 hours (range 0:38 to 13:00 hours); in the regional hospitals, it is 1:37 hours (range 0:46 to 2:47 minutes). The average time for the infusion center is 0:52 minutes (range 0:30 to 1:08 hour). Intravenous analgesia was the preferred route of opioid administration, representing 93% of the encounters. When we divided the main campus ED visits by age, the results showed an average time of 4:08 hours for adults (> 18 years) and 2:37 hours for the pediatric (< 18 years) population, which means that the pediatric population receives the first analgesic 42% earlier than the adult population.

Discussion:

Prolonged wait times and inefficient/ineffective ED management are potent negative drivers of quality of life in people with sickle cell disease, resulting in patient dissatisfaction, ongoing pain, and recurrent ED utilization. In our institution, the ED's average time for initial analgesic is longer when compared with the infusion center and the 2020 ASH guideline for acute pain management. Age plays a significant role in pain management, with a prolonged waiting time in adult patients compared to pediatric patients. This study demonstrates the importance of the individualized pain plan (IPP) and the need for a multidisciplinary discussion of the plan of care as a clinical tool to decrease ED waiting time and hospital admissions as noted by Osunkwo et al.

Conclusions:

This study represents a baseline for quality improvement measures in the ED with a long-term goal of creating institutional practices for patients with SCD including the development of IPPs and institutional clinical guidelines for our SCD patients. In subsequent studies, variables such as adequate SCD-directed training and adherence to IPP should be addressed.

Albright:Pfizer: Speakers Bureau. Hanna:AbbVie: Consultancy; Vertex: Membership on an entity's Board of Directors or advisory committees, Other: Advisory Board; SOBI: Speakers Bureau; Sanofi: Consultancy.