Emergency Department Management of Acute Pain Episodes in Sickle Cell Disease

Authors

  • Paula Tanabe PhD, RN, MPH,

    Corresponding author
    1. Department of Emergency Medicine (PT, RM, AZ), Institute for Healthcare Studies (PT), Mental Health Services and Policy Program (ZM), and Division of Hematology-Oncology, Feinberg School of Medicine (JAP), Northwestern University, Chicago, IL
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  • Randall Myers MS, MD,

    1. Department of Emergency Medicine (PT, RM, AZ), Institute for Healthcare Studies (PT), Mental Health Services and Policy Program (ZM), and Division of Hematology-Oncology, Feinberg School of Medicine (JAP), Northwestern University, Chicago, IL
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  • Amy Zosel MD,

    1. Department of Emergency Medicine (PT, RM, AZ), Institute for Healthcare Studies (PT), Mental Health Services and Policy Program (ZM), and Division of Hematology-Oncology, Feinberg School of Medicine (JAP), Northwestern University, Chicago, IL
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  • Jane Brice MD, MPH,

    1. Department of Emergency Medicine, University of North Carolina (JB), Chapel Hill, NC
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  • Altaf H. Ansari MD,

    1. Department of Emergency Medicine (AHA, JE) and Pain and Emergency Medicine Institute (KHT), Beth Israel Medical Center, New York, NY
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  • Julia Evans MD,

    1. Department of Emergency Medicine (AHA, JE) and Pain and Emergency Medicine Institute (KHT), Beth Israel Medical Center, New York, NY
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  • Zoran Martinovich PhD,

    1. Department of Emergency Medicine (PT, RM, AZ), Institute for Healthcare Studies (PT), Mental Health Services and Policy Program (ZM), and Division of Hematology-Oncology, Feinberg School of Medicine (JAP), Northwestern University, Chicago, IL
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  • Knox H. Todd MD, MPH,

    1. Department of Emergency Medicine (AHA, JE) and Pain and Emergency Medicine Institute (KHT), Beth Israel Medical Center, New York, NY
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  • Judith A. Paice PhD, RN

    1. Department of Emergency Medicine (PT, RM, AZ), Institute for Healthcare Studies (PT), Mental Health Services and Policy Program (ZM), and Division of Hematology-Oncology, Feinberg School of Medicine (JAP), Northwestern University, Chicago, IL
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(Email: ptanabe2@nmff.org).

Abstract

ObjectivesTo characterize the initial management of patients with sickle cell disease and an acute pain episode, to compare these practices with the American Pain Society Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease in the emergency department, and to identify factors associated with a delay in receiving an initial analgesic.

MethodsThis was a multicenter retrospective design. Consecutive patients with an emergency department visit in 2004 for an acute pain episode related to sickle cell disease were included. Exclusion criteria included age younger than 18 years. A structured medical record review was used to abstract data, including the following outcome variables: analgesic agent and dose, route, and time to administration of initial analgesic. Additional variables included demographics, triage level, intravenous access, and study site. Mann–Whitney U test or Kruskal–Wallis test and multivariate regression were used to identify differences in time to receiving an initial analgesic between groups.

ResultsThere were 612 patient visits, with 159 unique patients. Median time to administration of an initial analgesic was 90 minutes (25th to 75th interquartile range, 54–159 minutes). During 87% of visits, patients received the recommended agent (morphine or hydromorphone); 92% received the recommended dose, and 55% received the drug by the recommended route (intravenously or subcutaneously). Longer times to administration occurred in female patients (mean difference, 21 minutes; 95% confidence interval = 7 to 36 minutes; p = 0.003) and patients assigned triage level 3, 4, or 5 versus 1 or 2 (mean difference, 45 minutes; 95% confidence interval = 29 to 61 minutes; p = 0.00). Patients from study sites 1 and 2 also experienced longer delays.

ConclusionsPatients with an acute painful episode related to sickle cell disease experienced significant delays to administration of an initial analgesic.

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