Development of a Decision Support Tool to Guide Management of Adults with Sickle Cell Disease: The Emergency Department Sickle Cell Assessment of Strengths and Needs (ED-SCANS).

There are relatively few centers across the United States that either specialize in SCD care or have day hospitals where patients can be evaluated and urgently treated for acute pain crises. While most patients come to the ED for management of an acute pain crisis, SCD patients are at risk for many life-threatening complications. Most patients with SCD require an ED visit at some point. The complexity of SCD warrants a comprehensive assessment in the emergency department. While it may be challenging to conduct such an assessment in the ED, a succinct decision support tool may help guide clinicians in the performance of such an assessment. The benefits of such an assessment would identify unmet patient needs and help guide ED management and referrals. The goal of this project was to develop a brief, easy to use tool that guides the emergency clinicians in the identification of such needs and aid in accomplishing the following goals: 1) rapidly and aggressively manage ED pain, 2) identify other life-threatening conditions, 3) decrease hospital admission rates, 4) decrease return visits to the ED, 5) identify and increase the number of referrals made from the ED setting, and 6) increase both patient and clinician satisfaction with the ED experience.

A series of seven clinician and patient focus groups were conducted in four cities across the United States (Chicago, Denver, Durham, and New York) to obtain key stakeholder input. Visits at three SCD centers of excellence (University of Colorado Denver, Duke University, Virginia Commonwealth University) were conducted, a literature search was conducted, and the PI attended SCD clinics to observe practice patterns with sickle cell experts at the University of Illinois and University of Chicago sickle cell clinics. Focus group data was analyzed using qualitative methods and is reported elsewhere. All data was synthesized and a draft tool was created and reviewed by outside experts. Revisions were made.

The following six key decisions were identified as being critical in achieving the tools aims: (1) what is the correct triage level, (2) how should pain be treated, (3) does the patient require a diagnostic work-up, (4) should the patient be admitted to the hospital, (5) if discharged home, is there a need for analgesic prescriptions, and (6) does the patient need a referral to a sickle cell expert or mental health or social services? Supporting data elements for each decision were also identified and included as part of the tool which will be formulated into an easy to use algorithm. Data elements include key history and physical indicators of a potential high risk situation necessitating further evaluation, pain assessment and history of analgesic use, relationship with a sickle cell expert, ED and hospital utilization history, and evaluation of psychosocial needs (self-report of anxiety or depression, work/employment status, home situation).

Critical decisions and associated supporting elements to facilitate ED management were identified. Future work will involve finalizing and testing this communimetric tool, which will guide emergency department evaluation and management, as well as guide analgesic management in real time.

Tanabe: NIH, and Mayday Fund: Research Funding. Todd: NIH: Research Funding; Xanodyne: Consultancy; Merck: Consultancy; Alpharma: Consultancy; Abbott: Consultancy; Baxter Healthcare: Consultancy; Fralex Therapeutics: Consultancy; Intranasal Therapeutics: Consultancy; Baxter Health: Research Funding; Roxro: Consultancy.