Pain Control Practices in Sickle Cell Patients Presenting to the Emergency Department

Abstract

Many emergency departments struggle with treating vasoocclusive crises (VOC) in patients diagnosed with sickle cell anemia. The purpose of this study was to evaluate emergency department (ED) providers in their treatment of patients with VOC. National Institute of Health (NIH) guidelines for treating VOC were used as the standard, and retrospective data was analyzed to compare how ED providers adhered to these guidelines over the course of five years (2012-2017). Triage acuity, time to initial analgesia, and efficacy of pain control were specifically analyzed per NIH guidelines. Patient attributes including insurance status, gender, and utilization of outpatient provider were also analyzed to determine if these factors influence pain control and ultimately, disposition. We found that the majority of patients presenting with VOC were not triaged at the Emergency Severity Index (ESI) Level 2, not given their first dose of medications within thirty minutes of arrival, and did not have a > 2 point change in their pain score from baseline to discharge. When looking at predictors of pain scores, type of insurance had a significant increase in pain scores when compared to Medicaid and patients with established outpatient follow up overall had decreased pain scores. Patients were more likely to be admitted with increasing age, if they were followed by an outpatient hematologist, and if they received higher doses of opioid equivalents while in the ED. Patients with established outpatient follow up and those who were ultimately admitted both received higher amounts of opioid equivalents during their ED visit. There was no significant difference in morphine equivalents given over time based on insurance status or age. Our results show that pain control of VOC in sickle cell patients is poorly managed in the ED setting and that NIH guidelines are generally not adhered to, leaving room for significant improvement.