Patients with sickle cell disease utilize hospital emergency room (ER) for treatment of acute pain crisis. American Pain Society placed a guideline that pain medication be given within 20 minutes of entrance to ER. In our previous study (unpublished) in 2007 and 2008 (1st period) [a retrospective review of ER visits at Hurley Medical Centre (HMC)], we noted a great delay in this interval. Since then we made efforts to educate ER providers, and also educated patients regarding adherence to hydroxyurea medication, so that their visits to ER will decrease in frequency. Our aim was to determine if there was an improvement during the 2nd period (2011‐2012) compared to the 1st period (2007‐2008) regarding the interval time between ER entrance to the 1st pain medication given, and a decrease in the frequency of ER visits by sickle cell patient for pain crisis.
We made a retrospective chart review of all ER visits by sickle cell patients (Hb SS, SC, S/β thlassemia) and with a discharge diagnosis of ICD‐9 codes of sickle cell disease with pain crisis that occurred from January 1, 2011 to December 31, 2012. Independent t‐test, Chi‐square analysis and Kruskal‐Wallis test were used for analysis. Data were compared to period 1 data obtained previously.
During the period 2 (2011‐2012), there were 111 patients and 980 ER encounters. Seventy three patients (65.7%) with 896 encounters (average 12.3 ER visits/patient) were adults (age ≥19) and 38 patients (34.2%) with 84 encounters (2.2 visits/patient) were children (age ≤18). The mean length of stay in the ED was 327.14 ± 208.41 minutes for pediatric patients compared to 444.11 ± 243.32 minutes for adult patients (p <0.001). The mean pain score for pediatric population was 7.36±3.33 compared to 9.32±1.07 for adult population (p<0.001). The mean pain score for adult male patients was 8.7 compared to 9.5 for adult female patients (p<0.001) while the mean time to receiving the first analgesic for adult male patients was 92.45 minutes compared to 125.5 minutes for adult female patients (p<0.001). Among the pediatric patients 8.4% received the first analgesic within the first 20 minutes of ER stay compared to 1% of adult patients (p<0.001). Seventy‐one per cent of pediatric patients failed to receive the first pain medications within the first 60 minutes from the ER entrance, while 82% of adult patients failed to do so(p<0.001). The forty‐two percent of the pediatric patients were subsequently hospitalized compared to 17 % of adult patients (p<0.001).
Comparisons between period 1 and period 2 are as follows:
|Period 2 (2011‐12)||Period 1 (2007‐08)||P value|
|Time to 1st analgesics (minutes) (adults)||116.7±75||151.2±124.6||<0.0001|
|Length of ER stay (minutes)(adults)||444.1±243.3||499.8±227.9||P<0.05|
|Initial pain scale (Peds)||7.36±3.3||9±1.3||P<0.05|
|No. ER visits, patients and encounters /patient (adults)||896, 73, 12.3||529, 45,11.7|
|No. ER visits, patients and encounters/patient (Peds)||84, 38, 2.2||114, 44, 2.5|
We conclude that while there has been an improvement, there are still significant delays to administration of initial analgesic in our ER. Number of pediatric patients visiting ER significantly decreased between these 2 periods, while this trend was not observed for adult patients. There may be multiple reasons for this trend, but emphasis on hydroxyurea adherence has been mainly on pediatric patients, and this may explain the reduced number of ER visits by pediatric patients.
To cite this abstract:Khan I, Mushtaq R, Clapham P, Inoue S, LaChance J. Management of Sickle Cell Pain Crisis at an Urban Community Hospital Emergency Room (Er). a Comparison of Two Periods. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 117. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/management-of-sickle-cell-pain-crisis-at-an-urban-community-hospital-emergency-room-er-a-comparison-of-two-periods/. Accessed January 19, 2020.