Compliance with Expert Recommendations of Sickle Cell Pain Management—a Single Institution Review

Introduction:

Sickle cell disease in a lifelong disorder associates with the occurrence of recurrent painful vasoocclusive crisis that often result in frequent emergency room trips and inpatient hospital stays. There are several goals in the management of sickle cell disease including early resolution of painful crisis and reduction of end stage events such as pulmonary hypertension and stroke. Unfortunately, the painful crisis leads to frequent ER visits and sometimes results in lengthy hospital stays. In 2014, The US Department of Health and Human Services came out with an expert report panel dictating recommendations on care for patient with sickle cell disease recommending pain medicine in the emergency room within one hour of triage and use of personal controlled analgesia (PCA) pumps. We opted to look at patient records within Orlando Health, a center with a large sickle cell patient population, to determine if we are following these recommendations.

Methods: We reviewed emergency room and inpatient records of 158 patients. We documented if pain medications were started within two hours of arrival to the emergency room (we allowed additional time to account for registration and triage) and we reviewed inpatient records for PCA use. We also looked for trends in PCA use in terms of complexity of hospital stays and length of stay.

Results:

For sickle cell patients coming into the emergency room, 107/158 (68%) were given pain medication within 2 hours of registration.

Of patients admitted to the hospital, only 10/158 (6%) were given a PCA pump. The patients given a PCA pump had an average length of stay of 16 days compared to the general population of 6.1 days. PCA use increased during lengthy hospitalizations rather than being started immediately.

The patients who were given a PCA pump were assigned an ER acuity score of 3 compared to the general population of 2.1.

Discussion:

In caring for patients with sickle cell disease, we often aim to provide quick and effective management of pain crisis. In terms of emergency room management, triage to pain medication time is ideally within one hour. By looking at an extended window to account for registration time, we were able to provide pain medication on time 68% of the time. Per pharmacy staff, the pain medications are kept in the emergency room pharmacy system and should be immediately available upon request. Emergency room physicians identify overcrowding of the ER and the prospect of patient addiction as potential barriers to more immediate access. This thought process can lead to unnecessary suffering from patients.

Inpatient PCA use was very infrequently started. Currently the hospitalist service is starting most of the inpatient pain medication. When asked about PCA use, the hospitalist physicians mostly stated that their experience hasn't shown a trend toward shorter length of stay. Additionally, patients frequently state that they prefer push medication to PCA use. Data does exist that the opposite is true, PCA use is associated with shorter length of stay. Education on this data and encouragement of PCA use with patients should be encouraged per expert recommendations. It does appear that PCA use is reserved for patients who are deemed "sicker" or have longer length of stay.

We believe these trends are reflective of other institutions and broad education on best management of sickle cell pain crisis may be required.