Adult Emergency Department Patients with Sickle Cell Pain Crisis: A Learning Collaborative Model to Improve Analgesic Management

Authors

  • Paula Tanabe PhD, MPH,

    1. From the Department of Emergency Medicine (PT, DMC, EZ), the Institute for Healthcare Studies (PT, KBW, EZ), the Division of General Internal Medicine (KBW), and the Division of Psychology, Mental Health Services and Policy Program (ZM), Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Medicine, University of Chicago Medical Center (NA), Chicago, IL; the American Board of Medical Specialties (KW), Chicago, IL; and the Department of Surgery, Division of Emergency Medicine, University of Illinois College of Medicine at Peoria, and OSF Saint Francis Medical Center (JWH), Peoria, IL.
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  • Nicole Artz MD,

    1. From the Department of Emergency Medicine (PT, DMC, EZ), the Institute for Healthcare Studies (PT, KBW, EZ), the Division of General Internal Medicine (KBW), and the Division of Psychology, Mental Health Services and Policy Program (ZM), Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Medicine, University of Chicago Medical Center (NA), Chicago, IL; the American Board of Medical Specialties (KW), Chicago, IL; and the Department of Surgery, Division of Emergency Medicine, University of Illinois College of Medicine at Peoria, and OSF Saint Francis Medical Center (JWH), Peoria, IL.
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  • D. Mark Courtney MD,

    1. From the Department of Emergency Medicine (PT, DMC, EZ), the Institute for Healthcare Studies (PT, KBW, EZ), the Division of General Internal Medicine (KBW), and the Division of Psychology, Mental Health Services and Policy Program (ZM), Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Medicine, University of Chicago Medical Center (NA), Chicago, IL; the American Board of Medical Specialties (KW), Chicago, IL; and the Department of Surgery, Division of Emergency Medicine, University of Illinois College of Medicine at Peoria, and OSF Saint Francis Medical Center (JWH), Peoria, IL.
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  • Zoran Martinovich PhD,

    1. From the Department of Emergency Medicine (PT, DMC, EZ), the Institute for Healthcare Studies (PT, KBW, EZ), the Division of General Internal Medicine (KBW), and the Division of Psychology, Mental Health Services and Policy Program (ZM), Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Medicine, University of Chicago Medical Center (NA), Chicago, IL; the American Board of Medical Specialties (KW), Chicago, IL; and the Department of Surgery, Division of Emergency Medicine, University of Illinois College of Medicine at Peoria, and OSF Saint Francis Medical Center (JWH), Peoria, IL.
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  • Kevin B. Weiss MD, MPH,

    1. From the Department of Emergency Medicine (PT, DMC, EZ), the Institute for Healthcare Studies (PT, KBW, EZ), the Division of General Internal Medicine (KBW), and the Division of Psychology, Mental Health Services and Policy Program (ZM), Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Medicine, University of Chicago Medical Center (NA), Chicago, IL; the American Board of Medical Specialties (KW), Chicago, IL; and the Department of Surgery, Division of Emergency Medicine, University of Illinois College of Medicine at Peoria, and OSF Saint Francis Medical Center (JWH), Peoria, IL.
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  • Elena Zvirbulis MS,

    1. From the Department of Emergency Medicine (PT, DMC, EZ), the Institute for Healthcare Studies (PT, KBW, EZ), the Division of General Internal Medicine (KBW), and the Division of Psychology, Mental Health Services and Policy Program (ZM), Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Medicine, University of Chicago Medical Center (NA), Chicago, IL; the American Board of Medical Specialties (KW), Chicago, IL; and the Department of Surgery, Division of Emergency Medicine, University of Illinois College of Medicine at Peoria, and OSF Saint Francis Medical Center (JWH), Peoria, IL.
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  • John W. Hafner MD, MPH

    1. From the Department of Emergency Medicine (PT, DMC, EZ), the Institute for Healthcare Studies (PT, KBW, EZ), the Division of General Internal Medicine (KBW), and the Division of Psychology, Mental Health Services and Policy Program (ZM), Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Medicine, University of Chicago Medical Center (NA), Chicago, IL; the American Board of Medical Specialties (KW), Chicago, IL; and the Department of Surgery, Division of Emergency Medicine, University of Illinois College of Medicine at Peoria, and OSF Saint Francis Medical Center (JWH), Peoria, IL.
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  • Presented at the Sickle Cell Disease Association of America meeting, New Orleans, LA, September 2008; American College of Emergency Physicians meeting, Chicago, IL, October 2008; and the American Pain Society, San Diego, CA, May 2009.

  • This project was supported by a research grant from the Mayday Fund. Dr. Tanabe also received support from the NIH, K23NR010940.

Address for correspondence and reprints: Paula Tanabe, PhD, MPH; e-mail: ptanabe2@nmff.org.

Abstract

Objectives:  The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative.

Methods:  A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data.

Results:  A total of 155 patients met study criteria (median age = 32 years, IQR = 24–40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48–135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean ± SD = 4.19 ± 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean ± SD = 5.77 ± 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43).

Conclusions:  While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable.

ACADEMIC EMERGENCY MEDICINE 2010; 17:399–407 © 2010 by the Society for Academic Emergency Medicine

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