Adult emergency department patients with sickle cell pain crisis: A learning collaborative model to improve analgesic management

Paula Tanabe*, Nicole Artz, D Mark Courtney, Zoran Martinovich, Kevin B Weiss, Elena Zvirbulis, John W. Hafner

*Corresponding author for this work

Research output: Contribution to journalArticle

29 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)399-407
Number of pages9
JournalAcademic Emergency Medicine
Volume17
Issue number4
DOIs
StatePublished - Apr 23 2010

Fingerprint

Analgesics
Hospital Emergency Service
Learning
Pain
Sickle Cell Anemia
Interviews
Morphine
Hydromorphone
Ketorolac
Meperidine
Ibuprofen
Practice Management
Acute Pain
Quality Improvement
Health Services
Names
Medical Records
Longitudinal Studies
Cohort Studies
Nurses

Keywords

  • Analgesic management
  • Emergency
  • Learning collaborative
  • Pain
  • Sickle cell

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Tanabe, Paula ; Artz, Nicole ; Courtney, D Mark ; Martinovich, Zoran ; Weiss, Kevin B ; Zvirbulis, Elena ; Hafner, John W. / Adult emergency department patients with sickle cell pain crisis : A learning collaborative model to improve analgesic management. In: Academic Emergency Medicine. 2010 ; Vol. 17, No. 4. pp. 399-407.
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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.",
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Adult emergency department patients with sickle cell pain crisis : A learning collaborative model to improve analgesic management. / Tanabe, Paula; Artz, Nicole; Courtney, D Mark; Martinovich, Zoran; Weiss, Kevin B; Zvirbulis, Elena; Hafner, John W.

In: Academic Emergency Medicine, Vol. 17, No. 4, 23.04.2010, p. 399-407.

Research output: Contribution to journalArticle

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AU - Tanabe, Paula

AU - Artz, Nicole

AU - Courtney, D Mark

AU - Martinovich, Zoran

AU - Weiss, Kevin B

AU - Zvirbulis, Elena

AU - Hafner, John W.

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KW - Emergency

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