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Telfer P, Anie KA, Kotsiopoulou S, Aiken L, Hibbs S, Burt C, Stuart-Smith S, Lugthart S. The acute pain crisis in sickle cell disease: What can be done to improve outcomes? Blood Rev 2024; 65:101194. [PMID: 38553339 DOI: 10.1016/j.blre.2024.101194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/19/2024] [Accepted: 03/17/2024] [Indexed: 04/21/2024]
Abstract
The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.
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Affiliation(s)
- Paul Telfer
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, UK; Department of Haematology, Royal London Hospital, Bart's Health NHS Trust, London, UK.
| | - Kofi A Anie
- Brent Sickle Cell & Thalassaemia Centre, London North West University Healthcare NHS Trust, London, UK
| | | | - Laura Aiken
- Department of Haematology, Royal London Hospital, Bart's Health NHS Trust, London, UK
| | - Stephen Hibbs
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | | | - Sanne Lugthart
- University of Bristol, School of Cellular and Molecular Medicine, Bristol, UK; Department of Haematology, University Hospitals of Bristol, Bristol, UK
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Sanni A, Goble S, Gilbertson DT, Johnson D, Linzer M. The Associations Between Opioid Use Disorder and Healthcare-Related Outcomes in Vaso-occlusive Crisis. J Gen Intern Med 2024:10.1007/s11606-024-08717-7. [PMID: 38499723 DOI: 10.1007/s11606-024-08717-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 02/23/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND In patients who experience frequent vaso-occlusive crises (VOC), opioid dependence may be due to a need for pain control as opposed to addiction; the implications of opioid use disorder (OUD) in this population are unclear. OBJECTIVE To compare outcomes in hospitalizations for VOC in those with a history of OUD to those without a history of OUD. DESIGN A retrospective assessment of hospitalizations for adults in the USA with a primary discharge diagnosis of VOC using the National Inpatient Sample database from 2016 to 2019. We also compared VOC hospitalizations to hospitalizations for all other reasons to assess differences in OUD-associated clinical factors. PARTICIPANTS In total, 273,460 hospitalizations for VOC; 23,120 (8.5%) of these hospital stays involved a secondary diagnosis of OUD. MAIN MEASURES Primary outcomes were length of hospital stay and cost. Mortality was a secondary outcome. KEY RESULTS Hospital length of stay was increased (mean 6.2 vs 4.9 days) in patients with OUD (adjusted rate ratio = 1.24, 95% CI 1.20-1.29, p < 0.001). Mean cost was also higher in those with OUD ($9076) than those without OUD ($8020, p < 0.001). Mortality was decreased in VOC hospitalizations in those with OUD, but the difference was not statistically significant (adjusted OR = 0.64, 95% CI 0.028-1.48, p = 0.30). CONCLUSIONS OUD is associated with increased length of stay and costs in patients with VOC. While there are many possible explanations, providers should consider undertreatment of pain due to addiction concerns as a potential factor; individualized pain plans to mitigate this challenge could be explored.
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Affiliation(s)
- Abdulsabur Sanni
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Spencer Goble
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA.
| | - David T Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | | | - Mark Linzer
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
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Feeney C, Chandler M, Platt A, Sun S, Setji N, Ming DY. Impact of a hospital service for adults with chronic childhood-onset disease: A propensity weighted analysis. J Hosp Med 2023; 18:1082-1091. [PMID: 37933708 PMCID: PMC11097107 DOI: 10.1002/jhm.13234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Young adults with chronic childhood-onset diseases (CCOD) transitioning care from pediatrics to adult care are at high risk for readmission after hospital discharge. At our institution, we have implemented an inpatient service, the Med-Peds (MP) line, to improve transitions to adult care and reduce hospital utilization by young adults with CCOD. OBJECTIVE This study aimed to assess the effect of the MP line on length of stay (LOS) and 30-day readmission rates compared to other inpatient services. METHODS This was an observational, retrospective cohort analysis of patients admitted to the MP line compared to other hospital service lines over a 2-year period. To avoid potential confounding by indication for admission to the MP line, propensity score weighting methods were used. RESULTS The MP line cared for 302 patients with CCOD from June 2019 to July 2021. Compared to other service lines, there was a 33% reduction in relative risk of 30-day readmission (26.9% compared to 40.3%, risk ratio = 0.67, 95% confidence interval [CI] 0.55-0.81). LOS was 10% longer for the MP line (event time ratio (ETR): 1.10 95% CI 1.0-1.21) with median LOS 4.8 versus 4.5 days. Patients with sickle cell disease had less of a reduction in 30-day readmissions and longer LOS. CONCLUSION Hospitalization for young adults with CCOD on a MP service line was associated with lower 30-day readmission rates and longer LOS than hospitalization on other services. Further research is needed to assess which components of the line most contribute to decreased utilization.
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Affiliation(s)
- Colby Feeney
- Duke University School of Medicine, Department of Medicine
- Duke University School of Medicine, Department of Pediatrics
| | - Mark Chandler
- Duke University School of Medicine, Department of Medicine
- Duke University School of Medicine, Department of Pediatrics
| | - Alyssa Platt
- Duke University, Department of Biostatistics and Bioinformatics
| | - Shifeng Sun
- Duke University, Department of Biostatistics and Bioinformatics
| | - Noppon Setji
- Duke University School of Medicine, Department of Medicine
- Duke University School of Medicine, Department of Pediatrics
| | - David Y. Ming
- Duke University School of Medicine, Department of Medicine
- Duke University School of Medicine, Department of Pediatrics
- Duke University School of Medicine, Department of Population Health Sciences
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Macey-Stewart KV, Louie K. Using an individualized pain management plan for African American adults with sickle cell disease. J Am Assoc Nurse Pract 2023; 35:434-440. [PMID: 37229519 DOI: 10.1097/jxx.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 04/11/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND The increased lifespan of individuals having sickle cell disease (SCD) causes an overall increase in hospitalizations and more instances in which pain may not be well controlled. LOCAL PROBLEM The mainstay treatment for severe pain is opioids and the underlying cause. Laws affecting opioid prescribing, implicit bias, racial inequity, poor research funding, and lack of knowledge contribute to poor patient outcomes. METHOD Data were collected retrospectively using electronic medical record data from before and after the intervention. INTERVENTION The individualized pain management plan (IPMP) was initiated in collaboration with the patient, pain nurse practitioner (NP), and hematologist. RESULT The mean length of stay for the traditional pain management plan (TPMP) was 7.89 days compared with 5.66 days for the IPMP, with a mean difference of 2.23 days, t = 2.278, p = .024 ( p < .05). There was a decrease in the admission of the individuals with the IPMP, with 25% readmitted within 30 days of discharge, versus 59.0% who were readmitted using the TPMP. Chi-square showed statistical significance (χ 2 = 61.667, p = .000) in using nonpharmacological interventions with the IPMP group. CONCLUSION The IPMP with a patient-centered approach did improve patient outcomes for African American adults living with SCD.
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Affiliation(s)
- Karen V Macey-Stewart
- School of Nursing, Loyola University New Orleans, New Orleans, Louisiana
- School of Nursing, William Paterson University, Wayne, New Jersey
| | - Kem Louie
- School of Nursing, William Paterson University, Wayne, New Jersey
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Wachnik AA, Welch-Coltrane JL, Adams MCB, Blumstein HA, Pariyadath M, Robinson SG, Saha A, Summers EC, Hurley RW. A Standardized Emergency Department Order Set Decreases Admission Rates and In-Patient Length of Stay for Adults Patients with Sickle Cell Disease. PAIN MEDICINE 2022; 23:2050-2060. [PMID: 35708651 PMCID: PMC9714532 DOI: 10.1093/pm/pnac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD. METHODS A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use. RESULTS There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792. CONCLUSIONS Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.
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Affiliation(s)
| | | | | | | | | | | | - Amit Saha
- Department of Anesthesiology and Pain Service Line
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine
| | - Robert W Hurley
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27051, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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Kanjee Z, Achebe MO, Smith WR, Burns RB. How Would You Treat This Patient With Acute and Chronic Pain From Sickle Cell Disease? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2022; 175:566-573. [PMID: 35404671 DOI: 10.7326/m22-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Sickle cell disease is prevalent in large numbers of patients in the United States and has a significant global impact. Its complications span numerous organs and lead to reduced life expectancy. Acute and chronic sickle cell pain is a common cause of patient suffering. The American Society of Hematology published updated guidelines on management of acute and chronic pain from sickle cell disease in 2019. Several of the recommendations are conditional and leave specific decisions to the treating physician. These include conditional recommendations about the use of ketamine for acute pain and the initiation and discontinuation of long-term opioid therapy for chronic pain. Here, 2 hematologists discuss these guidelines and make contrasting recommendations for the management of acute and chronic pain for a patient with sickle cell disease.
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Affiliation(s)
- Zahir Kanjee
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., R.B.B.)
| | - Maureen Okam Achebe
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (M.O.A.)
| | - Wally R Smith
- Division of General Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (W.R.S.)
| | - Risa B Burns
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., R.B.B.)
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Wang H, Liu Y, Shen J, Du T. Personalized nursing improves physical condition and life quality of patients undergoing interventional therapy for liver cancer. Am J Transl Res 2021; 13:14220-14228. [PMID: 35035768 PMCID: PMC8748081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/12/2021] [Indexed: 06/14/2023]
Abstract
Interventional therapy, which can prolong the survival of patients with liver cancer (LC), is an important means to treat the disease. During interventional therapy for LC, it is essential to make a targeted and detailed nursing plan to ameliorate the prognosis. The purpose of this study was to determine the application significance of personalized nursing in patients undergoing interventional therapy for LC. We retrospectively analyzed 136 patients with LC undergoing interventional therapy. Among them, 70 cases receiving personalized nursing were assigned to the observation group (OG), and the remaining 66 cases receiving routine nursing were the control group (CG). After nursing, sleep time of patients in the OG was significantly longer than that in CG. In addition, time to ambulation and hospital stay were shorter in the OG than in the CG. Furthermore, the OG exhibited significantly lower scores of visual analogue scale (VAS) and self-rating anxiety scale (SAS), as well as significantly reduced incidence of adverse reactions than the CG. Compared with the CG, the levels of serum alanine aminotransferase (AST), aspartate aminotransferase (ALT), and total bilirubin (TBIL) were significantly lower in the OG after nursing, while the level of albumin (ALB) was significantly increased. Moreover, patients in the OG showed significantly higher nursing satisfaction and quality of life scores than those in the CG. Therefore, personalized nursing has good prospects for usein interventional therapy for LC.
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Affiliation(s)
- Hui Wang
- Department of Interventional Therapy, Shanxi Provincial People's Hospital Taiyuan 030012, Shanxi Province, China
| | - Yu'e Liu
- Department of Interventional Therapy, Shanxi Provincial People's Hospital Taiyuan 030012, Shanxi Province, China
| | - Jing Shen
- Department of Interventional Therapy, Shanxi Provincial People's Hospital Taiyuan 030012, Shanxi Province, China
| | - Tian Du
- Department of Interventional Therapy, Shanxi Provincial People's Hospital Taiyuan 030012, Shanxi Province, China
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