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Yadav A, Munir F, Chan KH, Quraishi MZ, Harris TS, Brown DL, Menon N, Nguyen TT, Srivaths L. Oxygen saturation thresholds in managing sickle cell disease at US children's hospitals. Pediatr Blood Cancer 2024; 71:e30879. [PMID: 38279845 DOI: 10.1002/pbc.30879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/20/2023] [Accepted: 01/05/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Adequate oxygen saturation (SpO2 ) is crucial for managing sickle cell disease (SCD). Children with SCD are at increased risk for occult hypoxemia; therefore, understanding SpO2 threshold practices would help identify barriers to oxygen optimization in a population sensitive to oxyhemoglobin imbalances. We investigated SpO2 cutoff levels used in clinical algorithms for management of acute SCD events at children's hospitals across the United States, and determined their consistency with recommended national guidelines (SpO2 > 95%). METHODS Clinical pathways and algorithms used for the management of vaso-occlusive crisis (VOC) and acute chest syndrome (ACS) in SCD were obtained and reviewed from large children's hospitals in the United States. RESULTS Responses were obtained from 94% (140/149) of eligible children's hospitals. Of these, 63 (45%) had available clinical algorithms to manage VOC and ACS. SpO2 cutoff was provided in 71.4% (45/63) of clinical algorithms. Substantial variation in SpO2 cutoff levels was noted, ranging from ≥90% to more than 95%. Only seven hospitals (5% of total hospitals and 15.6% of hospitals with clinical algorithms available) specified oxygen cutoffs that were consistent with national guidelines. Hospitals geographically located in the South (46.8%; n = 29/62) and Midwest (54.8%; n = 17/31) were more likely to have VOC and ACS clinical algorithms, compared to the Northeast (26.5%; n = 9/34) and West (36.4%; n = 8/22). CONCLUSION There is inconsistency in the use of clinical algorithms and oxygen thresholds for VOC and ACS across US children's hospitals. Children with SCD could be at risk for insufficient oxygen therapy during adverse acute events.
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Affiliation(s)
- Aravind Yadav
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Faryal Munir
- Department of Pediatrics, Pediatric Hematology Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kok Hoe Chan
- Division of Hematology/Oncology, Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston), Houston, Texas, USA
| | - Mariam Z Quraishi
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Tomika S Harris
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Deborah L Brown
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Neethu Menon
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Trinh T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Lakshmi Srivaths
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
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Sleppy RM, Watson BD, Donohue PK, Seltzer RR. Caring for Hospitalized Children in Foster Care: Provider Training, Preparedness, and Practice. Hosp Pediatr 2023; 13:784-793. [PMID: 37622243 DOI: 10.1542/hpeds.2023-007138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND AND OBJECTIVES Children and youth in foster care (CYFC) have high rates of health care utilization, including inpatient care. The objective of this study was to explore the inpatient provider experience caring for CYFC. METHODS Semistructured interviews were conducted with inpatient pediatric providers from Mid-Atlantic hospitals. Interview questions focused on 3 domains: provider training and preparedness, practice challenges, and strategies to improve care for CYFC. Conventional content analysis was applied to interview transcripts. RESULTS Thirty-eight interviews were completed with providers from 6 hospitals, including 14 hospitalists, 1 advanced practice provider, 11 registered nurses, 10 social workers (SWs), and 2 case managers. Nearly all (90%) reported at least monthly interactions with CYFC. Themes related to training and preparedness to care for CYFC included: medical providers' lack of formal training, limited foster care knowledge, and feeling of preparedness contingent on access to SWs. Themes related to unique practice challenges included: identifying CYFC, obtaining consent, documenting foster care status, complex team communication, and navigating interpersonal stress. Participants' suggestions for improving their ability to care for CYFC included increasing SW capacity, expanding provider training, standardizing electronic medical record documentation and order sets, and improving team communication and information sharing. CONCLUSIONS There are unique medical, social, and legal aspects of caring for hospitalized CYFC; pediatric medical providers receive limited training on these topics and rely heavily on SWs to navigate associated practice challenges. Targeted educational and health information technology interventions are needed to help inpatient providers feel better prepared to effectively meet the needs of CYFC.
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Affiliation(s)
- Rosalie M Sleppy
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Breanna D Watson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Pamela K Donohue
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rebecca R Seltzer
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Berman Institute of Bioethics, Baltimore, Maryland
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Fishman I, Siden H, Vadeboncoeur C. Evaluation of children with severe neurological impairment admitted to hospital with pain and irritability. BMC Pediatr 2022; 22:571. [PMID: 36195849 PMCID: PMC9531516 DOI: 10.1186/s12887-022-03632-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is the most common symptom reported by caregivers of children with severe neurological impairment (SNI), a descriptive term for children with disorders affecting the neurological system across multiple domains. In SNI, cognition, communication, and motor skills are impaired and other organ systems are impacted. Pain is difficult to identify and treat in children with SNI because of communication impairment. When a clear cause of pain is not determined, the term "Pain and Irritability of Unknown Origin (PIUO)" is used to describe pain-like behaviours. This study explores the clinical care received by children with SNI admitted to hospital after presenting to the emergency department of a tertiary pediatric hospital with pain or irritability. Findings are compared to the approach suggested in the PIUO pathway, an integrated clinical pathway for identifying and treating underlying causes of pain and irritability in children with complex conditions and limited communication. METHODS Retrospective chart review of children (age 0 to 18 years inclusive) with diagnoses compatible with SNI presenting with pain, irritability, and/or unexplained crying that required hospitalization between January 1st, 2019 and December 31st, 2019. Descriptive statistics were used to analyze the clinical care received by children in whom a source of pain was identified or not. In children for whom no cause of pain was identified, investigations completed were compared to the PIUO pathway. RESULTS Eight hospital admissions of six unique children were included for data analysis. A cause for pain and irritability was identified and resolved in three patients. In children with PIUO, there were gaps in history taking, physical examination, and investigations that might have allowed a cause of pain and irritability to be found. Pain was assessed using the r-FLACC pain scale and varying medications for pain/irritability were given during each hospital admission. CONCLUSION Children with SNI admitted to a tertiary pediatric hospital did not undergo a standardized approach to identifying a cause of pain and irritability. Future efforts should explore the effectiveness of the PIUO pathway, a standardized approach to reducing and resolving pain in children with SNI.
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Affiliation(s)
- Isobel Fishman
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Harold Siden
- British Columbia Children's Hospital Research Institute, Vancouver, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Canuck Place Children's Hospice, Vancouver, Canada
| | - Christina Vadeboncoeur
- Faculty of Medicine, University of Ottawa, Ottawa, Canada. .,Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario, K1H 8L1, Canada. .,Roger Neilson House, Ottawa, Canada.
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Rozenfeld S, Uppal H, Hesselbach K, Hetzel S, Ludwig T, Bice MJ, Williams SK. Pain Plan Implementation Effect: Analysis of Postoperative Opioid Use, Hospital Length of Stay, and Clinic Resource Utilization for Patients Undergoing Elective Spine Surgery. J Am Acad Orthop Surg 2022; 30:e1122-36. [PMID: 35468099 DOI: 10.5435/JAAOS-D-21-01237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/09/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The Pain Plan was developed collaboratively and implemented a unique systematic approach to reduce opioid usage in elective spine surgery. METHODS This was a retrospective cohort study comparing patients who underwent elective spine surgery before and after Pain Plan implementation. The Pain Plan was implemented on May 1, 2019. The experimental group comprised patients over the subsequent 1-year period with a Pain Plan (n = 319), and the control group comprised patients from the previous year without a Pain Plan (n = 385). Outcome variables include hospital length of stay (LOS), inpatient opioid use, outpatient opioid prescription quantities, number of clinic communication encounters, and communication encounter complexity. Patients were prospectively divided into three surgical invasiveness index subgroups representing small-magnitude, medium-magnitude, and large-magnitude spine surgeries. RESULTS There was a statistically significant decrease in hospital LOS ( P = 0.028), inpatient opioid use ( P = 0.001), and the average number of steps per communication encounter ( P = 0.010) for Pain Plan patients and a trend toward decreased outpatient opioid prescription quantities ( P = 0.052). No difference was observed in patient-reported pain scores. Statistically significant decreases in inpatient opioid use were seen in large-magnitude (50% reduction, P < 0.001) and medium-magnitude surgeries (49% reduction, P < 0.001). For small-magnitude surgeries, there was no difference (1.7% reduction, P = 0.99). The median LOS for large-magnitude surgeries decreased by 38% (20.5-hour decrease, P < 0.001) and decreased by 34% for medium-magnitude surgeries (17-hour difference, P = 0.055). For small-magnitude surgeries, there was no significant difference ( P = 0.734). Outpatient opioid prescription quantities were markedly decreased in small-magnitude surgeries only. The total number of communication encounters was not statistically significant in any group. However, the number of steps within a communication encounter was significantly decreased ( P = 0.010), and staff survey respondents reported more efficient and effective postoperative pain management for Pain Plan patients. DISCUSSION Pain Plan implementation markedly decreased hospital LOS, inpatient opioid use and outpatient opioid prescription quantities, and clinic resource utilization in elective spine surgery patients.
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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 Med 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Rizakos S, Parmar A, Siden HH, Orkin J. The Parental Experience of Caring for a Child With Pain and Irritability of Unknown Origin. J Pain Symptom Manage 2022; 63:330-340. [PMID: 34343622 DOI: 10.1016/j.jpainsymman.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/30/2021] [Accepted: 07/26/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Approximately 73% of children with severe neurological impairment (SNI) can experience episodes of pain and irritability often of unknown origin (PIUO). Limited research exists on how these experiences of PIUO may affect parental caregivers and families. The primary objective of this study was to understand the parental caregiver experience of caring for a child with SNI who experiences persistent PIUO. METHODS We conducted a qualitative study using semi-structured interviews to explore the experience of parental caregivers of children with SNI. Interview guide questions focused on exploring pain behaviours, the diagnostic process, pharmacological and non-pharmacological management, healthcare-team support, discussion surrounding irritability, and family impact. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed by 2 independent reviewers using thematic analysis. RESULTS 15 parental caregivers were interviewed, with 93% being mothers and 33% being a visible minority. Interviews revealed 3 major themes: 1) Variations in Clinical Care for PIUO; 2) The Experience and Challenges of Living with PIUO); 3) Managing the Impact of PIUO on Parental Well Being. Interviews demonstrated that parent and child can be viewed as a dyad, in which the child's experience is inherently linked to the parental experience. CONCLUSION Parental caregivers described caring for a child with persistent PIUO as physically and emotionally exhausting, and negatively impacting family quality of life. Interviews highlighted avenues of future exploration for clinical care, including both enhanced management pathways for children and supportive resources for education and coping for parents.
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Affiliation(s)
- Sara Rizakos
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arpita Parmar
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada; Schulich School of Medicine and Dentistry, Western University, London ON, Canada
| | - Harold Hal Siden
- Department of Pediatrics, University of British Columbia, BC, Canada; Child and Family Research Institute, BC Children's Hospital, Vancouver, BC, Canada; Canuck Place Children's Hospice, Vancouver, BC, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada; Division of Pediatric Medicine, Complex Care Program, The Hospital for Sick Children, Toronto, Canada.
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Welch-Coltrane JL, Wachnik AA, Adams MCB, Avants CR, Blumstein HA, Brooks AK, Farland AM, Johnson JB, Pariyadath M, Summers EC, Hurley RW. Implementation of Individualized Pain Care Plans Decreases Length of Stay and Hospital Admission Rates for High Utilizing Adults with Sickle Cell Disease. Pain Med 2021; 22:1743-1752. [PMID: 33690845 PMCID: PMC8346918 DOI: 10.1093/pm/pnab092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Patients with sickle cell disease (SCD) face inconsistent effective analgesic management, leading to high inpatient healthcare utilization and significant financial burden for healthcare institutions. Current evidence does not provide guidance for inpatient management of acute pain in adults with sickle cell disease. We conducted a retrospective analysis of a longitudinal cohort quality improvement project to characterize the role of individualized care plans on improving patient care and reducing financial burden in high healthcare-utilizing patients with SCD-related pain. METHODS Individualized care plans were developed for patients with hospital admissions resulting from pain associated with sickle cell disease. A 2-year prospective longitudinal cohort quality improvement project was performed and retrospectively analyzed. Primary outcome measure was duration of hospitalization. Secondary outcome measures included: pain intensity; 7, 30, and 90-day readmission rates; cost per day; total admissions; total cost per year; analgesic regimen at index admission; and discharge disposition. RESULTS Duration of hospitalization, the primary outcome, significantly decreased by 1.23 days with no worsening of pain intensity scores. Seven-day readmission decreased by 34%. Use of intravenous hydromorphone significantly decreased by 25%. The potential cost saving was $1,398,827 as a result of this quality initiative. CONCLUSIONS Implementation of individualized care plans reduced both admission rate and financial burden of high utilizing patients. Importantly, pain outcomes were not diminished. Results suggest that individualized care plans are a promising strategy for managing acute pain crisis in adult sickle cell patients from both care-focused and utilization outcomes.
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Affiliation(s)
- Jena L Welch-Coltrane
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Anthony A Wachnik
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Meredith C B Adams
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Cherie R Avants
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Howard A Blumstein
- Department of Emergency Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Amber K Brooks
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Andrew M Farland
- Department of Hematology, Wake Forest School of Medicine, North Carolina, USA
| | - Joshua B Johnson
- Department of Internal Medicine Section of Hospital Medicine, Wake Forest University School of Medicine, North Carolina, USA
| | - Manoj Pariyadath
- Department of Emergency Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine, Wake Forest University School of Medicine, North Carolina, USA
| | - Robert W Hurley
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine, North Carolina USA
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157-1009, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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Duroseau Y, Beenhouwer D, Broder MS, Brown B, Brown T, Gibbs SN, Jackson K, Liang S, Malloy M, Romney M, Shani D, Simon J, Yermilov I. Developing an emergency department order set to treat acute pain in sickle cell disease. J Am Coll Emerg Physicians Open 2021; 2:e12487. [PMID: 34401866 PMCID: PMC8349222 DOI: 10.1002/emp2.12487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
STUDY OBJECTIVE Patients with sickle cell disease (SCD) have many emergency department visits because of painful vaso-occlusive episodes (VOE). Guidelines recommend treatment within 30 minutes of triage, but this is rarely achieved in clinical practice. Our goal was to develop an order set that is being implemented in the ED to facilitate and standardize emergency care for SCD patients in acute pain from VOEs presenting to the emergency department (ED) in New York City (NYC). METHODS Using a RAND/University of California, Los Angeles modified Delphi panel, we convened a multidisciplinary panel and reviewed evidence on how to best manage SCD pain in the ED. Panelists collaboratively developed then rated 202 items that could be included in an ED order set. RESULTS A consensus order set, a practical how-to guide for managing SCD pain in the ED, was developed based on items that received high median ratings. CONCLUSIONS The management of acute pain experienced during VOEs is critical to patients with SCD; ED order sets, such as this one, can help standardize pain management, including at triage, evaluation, discharge, and follow-up care. After implementation in NYC EDs, studies to examine changes in quality care metrics (eg, wait times, readmissions) are planned.
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Affiliation(s)
- Yves Duroseau
- Department of Emergency MedicineLenox Hill Hospital/Northwell HealthNew YorkNew YorkUSA
| | - David Beenhouwer
- Partnership for Health Analytic Research (PHAR)Beverly HillsCaliforniaUSA
| | - Michael S Broder
- Partnership for Health Analytic Research (PHAR)Beverly HillsCaliforniaUSA
| | - Bonnie Brown
- Observation MedicineMount Sinai Morningside and WestNew YorkNew YorkUSA
| | - Tartania Brown
- Metropolitan Jewish Healthcare SystemDepartment of Family and Social MedicineAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Sarah N Gibbs
- Partnership for Health Analytic Research (PHAR)Beverly HillsCaliforniaUSA
| | - Kaedrea Jackson
- Department of Emergency MedicineMount Sinai MorningsideNew YorkNew YorkUSA
| | - Sally Liang
- Mount Sinai Beth IsraelEmergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Melanie Malloy
- Emergency MedicineMount Sinai BrooklynIcahn School of Medicine at Mount SinaiBrooklynNew YorkUSA
| | - Marie‐Laure Romney
- Quality and Patient SafetyDepartment of Emergency MedicineColumbia UniversityNew YorkNew YorkUSA
| | - Dana Shani
- Departments of Hematology, Medical Oncology and Internal MedicineLenox Hill Hospital/Northwell HealthNew YorkNew YorkUSA
| | - Jena Simon
- Adult Program for Sickle Cell at Mount Sinai HospitalNew YorkNew YorkUSA
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR)Beverly HillsCaliforniaUSA
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Poonai N, Kumar K, Coriolano K, Thompson G, Brahmbhatt S, Dzongowski E, Stevens H, Gupta P, Miller M, Elsie S, Ashok D, Joubert G, Lim R, Bütter A, Ali S. Hyoscine butylbromide versus acetaminophen for nonspecific colicky abdominal pain in children: a randomized controlled trial. CMAJ 2020; 192:E1612-E1619. [PMID: 33257343 DOI: 10.1503/cmaj.201055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Less than two-thirds of children with abdominal pain in the emergency department receive analgesia. We sought to determine whether hyoscine butylbromide was superior to acetaminophen for children with nonspecific colicky abdominal pain. METHODS We randomly allocated children aged 8-17 years with nonspecific colicky abdominal pain who presented to the pediatric emergency department of London Health Sciences Centre, London, Ontario to receive hyoscine butylbromide, 10 mg given orally, or acetaminophen, 15 mg/kg given orally (maximum 975 mg). We considered the minimal clinically important difference for the primary outcome (self-reported pain at 80 min) to be 13 mm on a 100 mm visual analogue scale. Secondary outcomes included administration of rescue analgesia, adverse effects and pain score less than 30 mm at 80 minutes. RESULTS A total of 236 participants (120 in the hyoscine butylbromide group and 116 in the acetaminophen group) were included in the trial. The mean visual analogue scale scores at 80 minutes were 29 mm (standard deviation [SD] 26 mm) and 30 mm (SD 29 mm) with hyoscine butylbromide and acetaminophen, respectively (adjusted difference 1, 95% confidence interval -7 to 7). Rescue analgesia was administered to 4 participants (3.3%) in the hyoscine butylbromide group and 1 participant (0.9%) in the acetaminophen groups (p = 0.2). We found no significant differences in rates of adverse effects between hyoscine butylbromide (32/116 [27.6%]) and acetaminophen (28/115 [24.3]) (p = 0.5); no serious adverse effects were observed. The proportion with a pain score less than 30 mm at 80 minutes was 66 (55.0%) with hyoscine butylbromide and 63 (54.3%) with acetaminophen (p = 0.9). INTERPRETATION Hyoscine butylbromide was not superior to acetaminophen in this setting. Both agents were associated with clinically important pain reduction, and either can be considered for children presenting to the emergency department with nonspecific colicky abdominal pain. Trial registration: Clinicaltrials.gov, no. NCT02582307.
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Affiliation(s)
- Naveen Poonai
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta.
| | - Kriti Kumar
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Kamary Coriolano
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Graham Thompson
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Shaily Brahmbhatt
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Emily Dzongowski
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Holly Stevens
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Priti Gupta
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Michael Miller
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Sharlene Elsie
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Dhandapani Ashok
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Gary Joubert
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Rod Lim
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Andreana Bütter
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Samina Ali
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
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Della-Moretta S, Delatore L, Purcell M, Huang Y, Heinlein M, Adkins E, Desai P. The Effect of Use of Individualized Pain Plans in Sickle Cell Patients Presenting to the Emergency Department. Ann Emerg Med 2020; 76:S21-S27. [PMID: 32928458 DOI: 10.1016/j.annemergmed.2020.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE Sickle cell disease (SCD) is an inherited hematologic disorder that affects approximately 100,000 US individuals and results in greater than 200,000 emergency department (ED) visits annually in the United States, with pain being the most common complaint. The objective of this retrospective study is to determine the effect of implementing individualized pain plans in the treatment of patients with SCD in the ED on time to first opioid, length of stay, and disposition. METHODS At The Ohio State University Wexner Medical Center, a multidisciplinary group including hematologists and ED physicians was formed and enacted a protocol for using individualized pain plans, with the goal of decreasing time to treatment for patients with SCD who presented to the ED with chief complaint of pain. In this retrospective study, data from the year before through the year of implementation were gathered. Generalized linear models were fit to compare time to first opioid, length of stay, and disposition before and after protocol implementation. RESULTS Data showed a 48% decrease in time to first opioid and a 22% decrease in length of ED stay after protocol implementation. No significant change was found in disposition or length of inpatient admission before and after protocol initiation. CONCLUSION The use of individualized pain plans in the treatment of patients with SCD in the ED is a useful method of not only ensuring rapid and adequate treatment but also decreasing use of health care resources.
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Affiliation(s)
| | | | | | - Ying Huang
- Department of Internal Medicine, Columbus, OH
| | - Melanie Heinlein
- Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Eric Adkins
- Department of Emergency Medicine, Columbus, OH
| | - Payal Desai
- Department of Internal Medicine, Columbus, OH; Division of Hematolgy, Columbus, OH.
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11
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Paquin H, Trottier ED, Pastore Y, Robitaille N, Dore Bergeron MJ, Bailey B. Evaluation of a clinical protocol using intranasal fentanyl for treatment of vaso-occlusive crisis in sickle cell patients in the emergency department. Paediatr Child Health 2020; 25:293-299. [PMID: 32765165 PMCID: PMC7395317 DOI: 10.1093/pch/pxz022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/26/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visits and admission in children with sickle cell disease (SCD). OBJECTIVES This study aims to evaluate whether the use of a new pain management pathway using intranasal (IN) fentanyl from triage leads to improved care, translated by a decrease in time to first opiate dose. METHODS We performed a retrospective chart review of patients with SCD who presented to the emergency department (ED) with VOC, in the period pre- (52 patients) and post- (44 patients) implementation period of the protocol. Time to first opiate was the primary outcome and was evaluated pre- and postimplementation. Patients received a first opiate dose within 52.3 minutes of registration (interquantile range [IQR] 30.6, 74.6), corresponding to a 41.4-minute reduction in the opiate administration time (95% confidence interval [CI] -56.1, -27.9). There was also a 43% increase in the number of patients treated with a nonintravenous (IV) opiate as first opiate dose (95% CI 26, 57). In patients who were discharged from the ED, there was a 49% decrease in the number of IV line insertions (95% CI -67, -22). There was no difference in the hospitalization rates (difference of 6 [95% CI -13, 25]). CONCLUSIONS This study validates the use of our protocol using IN fentanyl as first treatment of VOC in the ED by significantly reducing the time to first opiate dose and the number of IVs.
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Affiliation(s)
- Hugo Paquin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
| | - Evelyne D Trottier
- Department of Pediatrics, Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
| | - Yves Pastore
- Department of Pediatrics, Division of Hematology and Oncology, CHU Ste-Justine, Montréal, Quebec
| | - Nancy Robitaille
- Department of Pediatrics, Division of Hematology and Oncology, CHU Ste-Justine, Montréal, Quebec
| | | | - Benoit Bailey
- Department of Pediatrics, Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
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12
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Karkoska K, Appiah‐Kubi A, Rocker J, Stoffels G, Aygun B. Management of vaso‐occlusive episodes in the day hospital decreases admissions in children with sickle cell disease. Br J Haematol 2019; 186:855-860. [DOI: 10.1111/bjh.16002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/09/2019] [Accepted: 04/16/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Kristine Karkoska
- Cincinnati Children’s Hospital Medical Center Cancer and Blood Diseases Institute Cincinnati OH USA
| | - Abena Appiah‐Kubi
- Department of Pediatrics, Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation Cohen Children’s Medical Center of New York New Hyde Park NY USA
| | - Joshua Rocker
- Department of Pediatrics, Division of Emergency Medicine Cohen Children’s Medical Center of New York New Hyde Park NY USA
| | - Guillaume Stoffels
- Biostatistics Unit Feinstein Institute of Medical Research Manhasset NY USA
| | - Banu Aygun
- Department of Pediatrics, Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation Cohen Children’s Medical Center of New York New Hyde Park NY USA
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13
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Balsamo L, Shabanova V, Carbonella J, Szondy MV, Kalbfeld K, Thomas DA, Santucci K, Grossman M, Pashankar F. Improving Care for Sickle Cell Pain Crisis Using a Multidisciplinary Approach. Pediatrics 2019; 143:peds.2018-2218. [PMID: 30944154 DOI: 10.1542/peds.2018-2218] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Frequent hospitalizations for sickle cell disease (SCD) vaso-occlusive crises (VOCs) are associated with school absenteeism, emotional distress, and financial hardships. Our goal was to decrease hospital days for VOC admissions by 40% over a 5-year period. METHODS From October 2011 to September 2016, a multidisciplinary quality-improvement project was conducted with a plan-do-study-act methodology. Five key drivers were identified and 9 interventions implemented. Interventions included individualized home pain plans, emergency department and inpatient order sets, an inpatient daily schedule, psychoeducation, and a biofeedback program. High users (≥4 admissions per year) received an individualized SCD plan and assigned mental health provider. We expanded the high-use group to include at-risk patients (3 admissions per year). Data were analyzed for patients ages 0 to 21 years admitted for VOC. Hospital days were the primary measure; the 30-day readmission rate was the balancing measure. RESULTS A total of 216 SCD pediatric patients were managed in 2011 with a 14% increase over 5 years. A total of 122 patients were admitted for VOC. Hospital days decreased by 61% from 59.6 days per month in the preintervention period to 23.2 days per month in the postintervention period (P < .0001). Length of stay decreased from 4.78 (SD = 4.08) to 3.84 days (SD = 2.10; P = .02). Among high users, hospital days decreased from 35.4 to 15.5 days per month. The thirty-day readmission rate decreased from 33.9% to 19.4%. Overall savings in direct hospital costs per year were $555 120. CONCLUSIONS A dedicated team effort with simple interventions can have a significant impact on the well-being of a patient population and hospital costs.
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Affiliation(s)
- Lyn Balsamo
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; and
| | - Veronika Shabanova
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; and
| | - Judith Carbonella
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; and
| | | | | | - Donna-Ann Thomas
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; and
| | - Karen Santucci
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; and
| | - Matthew Grossman
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; and
| | - Farzana Pashankar
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; and
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Talebi Doluee M, Rezvani Kakhki B, Heidarian Mir H, Fateminayyeri M, Madanitorbati F, Hosseini S. Pain Relief in the Sickle-Cell Crisis: Intravenous Morphine Versus Ketorolac; A Double-Blind, Randomized Clinical Trial. Iran Red Crescent Med J 2019; In Press. [DOI: 10.5812/ircmj.83614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Knight LMJ, Onsomu EO, Bosworth HB, Crawford RD, DeMartino T, Glassberg J, Paice JA, Miller CN, Richardson L, Tanabe P. Exploring Emergency Department Provider Experiences With and Perceptions of Weight-Based Versus Individualized Vaso-Occlusive Treatment Protocols in Sickle Cell Disease. Adv Emerg Nurs J 2019; 41:86-97. [PMID: 30702538 DOI: 10.1097/TME.0000000000000232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Treatment of vaso-occlusive episodes (VOEs) is the most common reason for emergency department (ED) treatment of sickle cell disease (SCD). We (1) compared perceptions of the usability and ability to manage VOE pain between ED nurses and other ED provider types, ED sites, and VOE protocols (individualized vs. weight-based), and (2) identified ED nurse and other provider protocol suggestions. A secondary analysis of provider survey data collected immediately after caring for a patient enrolled in a randomized controlled trial comparing weight-based versus individualized opioid dosing for VOE. Research staff asked the ED nurses and other ED providers (nurse practitioners [NPs], physician assistants [PAs], residents, and attending physicians) 5 questions related to the protocol's ease of use and ability to manage pain. There were 236 surveys completed. Attending physicians (n = 15), residents (n = 88), PAs (n = 21), and NPs (n = l) were more satisfied than nurses (n = 111) with the clarity of the analgesic ordering (97.6% vs. 0%, p = 0.0001) and ability to manage the patient's VOE pain (91% vs. 0%, p = 0.0001). When comparing both protocols with the usual ED strategy in their ED to manage VOE, more nurses than other ED providers perceived the study patients' pain management protocol as better (100% vs. 35.2%, p = 0.0001). Other ED providers perceived the individualized versus weight-based protocol as better at managing pain than their usual ED strategy (70.3% vs. 59.5%, p = 0.04). The individualized protocol was perceived as better in managing VOE than the weight-based ED strategy. While physicians were satisfied with the clarity of the protocols, nurses were not. Improved protocol usability is required for widespread ED implementation.
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Abstract
This narrative review aims to highlight the current paradigm on pain management in sickle cell vaso-occlusive crisis. It specifically examines the pathophysiologic mechanisms of sickle cell pain as well as the pharmacologic and nonpharmacologic methods of pain management. Recurrent painful episodes constitute the major morbidity in sickle cell disease (SCD). While adolescents and young adults experience mostly acute episodic nociceptive pain, it is now recognized that a significant number of adult patients develop chronic neuropathic and centralized pain. In fact, current evidence points to an age-dependent increase in the frequency of SCD patients with chronic pain. Management of disease-related pain should be based on its pathophysiologic mechanisms instead of using recommendations from other non-SCD pain syndromes. Pain management in vaso-occlusive crisis is complex and requires multiple interventions such as pharmacologic, nonpharmacologic, and preventive therapeutic interventions. Pharmacologic treatment involves the use of non-opioid and opioid analgesics, and adjuvants - either singly or in combination - depending on the severity of pain. The basic approach is to treat SCD pain symptomatically with escalating doses of non-opioid and opioid analgesics. Given the moderate-to-severe nature of the pain usually experienced in this form of SCD crisis, opioids form the bedrock of pharmacologic treatment. Multimodal analgesia and structured, individualized analgesic regimen appear more effective in achieving better treatment outcomes. Although the current evidence is still limited on the supportive role of cognitive behavioral therapy in pain management, this nonpharmacologic approach is reportedly effective, but needs further exploration as a possible adjunct in analgesia.
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Affiliation(s)
- Samuel N Uwaezuoke
- Department of Pediatrics, College of Medicine, University of Nigeria, Enugu, Nigeria,
| | - Adaeze C Ayuk
- Department of Pediatrics, College of Medicine, University of Nigeria, Enugu, Nigeria,
| | - Ikenna K Ndu
- Department of Pediatrics, Enugu State University Teaching Hospital, Enugu, Nigeria
| | - Chizoma I Eneh
- Department of Pediatrics, Enugu State University Teaching Hospital, Enugu, Nigeria
| | - Ngozi R Mbanefo
- Department of Pediatrics, College of Medicine, University of Nigeria, Enugu, Nigeria,
| | - Osita U Ezenwosu
- Department of Pediatrics, College of Medicine, University of Nigeria, Enugu, Nigeria,
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17
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Schefft MR, Swaffar C, Newlin J, Noda C, Sisler I. A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department. Pediatr Blood Cancer 2018; 65:e27274. [PMID: 29856534 DOI: 10.1002/pbc.27274] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 05/11/2018] [Accepted: 05/13/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Vaso-occlusive crisis (VOC) is frequent in children with sickle cell disease (SCD) creating significant burden on patients, families, and emergency departments (ED). The objective of the project was to reduce the admission rate for children with SCD presenting to our ED with VOC by >20% within 6 months of initiating individualized pain plans (IPP). METHODS A multi-disciplinary quality improvement team was assembled. A Plan-Do-Study-Act (PDSA) format was employed. The IPP document was created in a unique folder within the electronic medical record. IPPs were created through retrospective chart review for our 80 highest resource users. Pediatric residents, ED residents, and ED attending physicians were instructed on use of the IPPs. Our study measured the presence of an IPP, adherence to the IPP, and time to opiate administration. Our primary outcome was admission rate. Length of stay and 72-hr return to the ED were assessed as balancing measures. RESULTS Overall, admission rate decreased by 24% following implementation compared with the previous 5 years (P = 0.046). IPPs were created for 78% of patients and followed by ED staff in 86% of visits. Admission rate was significantly lower for patients receiving a second opiate dose within 45 min of the first dose (P < 0.01). There was no difference in readmission rate or 72-hr return rate to ED. CONCLUSIONS This study presents an effective strategy to reduce admission rate for children with SCD presenting with VOC. Shorter time to second opiate dosing was also associated with reduced risk of admission.
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Affiliation(s)
- Matthew R Schefft
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University and Massey Cancer Center, Richmond, Virginia, USA
| | - Caitlan Swaffar
- Virgnia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Jennifer Newlin
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University and Massey Cancer Center, Richmond, Virginia, USA
| | - Cady Noda
- Department of Pharmacy Services, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - India Sisler
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University and Massey Cancer Center, Richmond, Virginia, USA
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18
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Paquin H, D Trottier E, Robitaille N, Pastore Y, Dore Bergeron MJ, Bailey B. Oral morphine protocol evaluation for the treatment of vaso-occlusive crisis in paediatric sickle cell patients. Paediatr Child Health 2018; 24:e45-e50. [PMID: 30792609 DOI: 10.1093/pch/pxy074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visit and admission in children with sickle cell disease (SCD). Objectives This study aimed to evaluate whether the implementation of a protocol promoting the use of oral morphine as a primary intervention has led to improved care of SCD. Methods We performed a retrospective chart review of patients with SCD who presented to the emergency department (ED) and hematology outpatient clinic (HOC) with VOC, in the year pre and postimplementation of the protocol. The primary outcome was the hospitalization rate. Results The protocol resulted in a significant 43% reduction of hospitalization rate (95% confidence interval [CI] -53.0, 26.5). Results also showed a 35% increase in the use of oral morphine as first-line opiate treatment (95% CI 17.9, 45.2), a 28% increase in the use of pain scales (95% CI 17.3, 43.2) and a 30% net increase in patients eventually not requiring intravenous (IV) line placement (95% CI 16.0, 39.9). While we did observe an overall decrease in length of stay in ED of -55 min (95% CI -100.6, -12.0), there was a nonsignificant decrease of 7 minutes (95% CI -26, 3) in the opiate administration time. Conclusions This study validates the use of our oral morphine protocol for the treatment of VOC by significantly reducing the admission rate and decreasing the number of IVs.
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Affiliation(s)
- Hugo Paquin
- Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
| | - Evelyne D Trottier
- Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
| | - Nancy Robitaille
- Division of Hematology and Oncology, CHU Ste-Justine, Montréal, Quebec
| | - Yves Pastore
- Division of Hematology and Oncology, CHU Ste-Justine, Montréal, Quebec
| | | | - Benoit Bailey
- Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
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19
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Ellison AM, Smith Whitley K, Kittick M, Schast A, Norris C, Hartung H, McKnight T, Coyne E, Lavelle J. A Standardized Clinical Pathway to Decrease Hospital Admissions Among Febrile Children With Sickle Cell Disease. J Pediatr Hematol Oncol 2018; 40:111-5. [PMID: 29252940 DOI: 10.1097/MPH.0000000000001052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Recurrent hospital admissions for patients with sickle cell disease (SCD) are costly and contribute to a low quality of life for patients. We implemented a clinical pathway to safely discharge SCD patients with fever who are evaluated in the emergency department (ED) of a large tertiary care center. METHODS An interdisciplinary team of ED and hematology physicians, nurses, and an improvement advisor developed a clinical pathway that identified febrile SCD patients at low risk of serious bacterial infection based on historical, clinical, and laboratory criteria who could be discharged from the ED. Phone follow-up was planned through the use of an automated electronic notification that was sent to an established hematology follow-up pool at the time of ED discharge. We conducted two "fake front end" trials in the ED to receive feedback on our process before full implementation. A postpathway implementation quality improvement team monitored discharge rates, phone follow-up rates and adverse events. RESULTS In the first 9 weeks postpathway implementation, 100 SCD patients were evaluated for fever; 84 (24%) met low-risk criteria and were discharged home. This reduction in admission rate has been maintained throughout the 3 years postimplementation. Successful phone follow-up was achieved in all discharged patients within 24 hours and no adverse events were identified. CONCLUSIONS Low-risk febrile patients with SCD can be safely discharged from the ED. An automated notification system within the electronic medical record system can facilitate patient follow-up after ED discharge. Future quality improvement efforts aimed to further reduce admissions in this population should target patients with modifiable risk factors for serious bacterial infection.
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Kim S, Brathwaite R, Kim O. Evidence-Based Practice Standard Care for Acute Pain Management in Adults With Sickle Cell Disease in an Urgent Care Center. Qual Manag Health Care 2017; 26:108-15. [PMID: 28375958 DOI: 10.1097/QMH.0000000000000135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: Vaso-occlusive episodes (VOEs) with sickle cell disease (SCD) require opioid treatment. Despite evidence to support rapid pain management within 30 minutes, care for these patients does not consistently meet this benchmark. This quality improvement study sought to decrease the first analgesic administration time, increase patient satisfaction, and expedite patient flow. Methods: A prospective pre-/postevaluation design was used to evaluate outcomes with patients 18 years or older with VOEs in an urgent care (UC) center after implementation of evidence-based practice standard care (EBPSC). A pre- and postevaluation survey of SCD patients' satisfaction with care and analogous surveys of the UC team to assess awareness of EBPSC were used. A retrospective review of the electronic medical records of patients with VOEs compared mean waiting time from triage to the first analgesic administration and the mean length of stay (LOS) over 6 months. Results: Implementing EBPSC decreased the mean time of the first analgesic administration (P = .001), significantly increased patient satisfaction (P = .002), and decreased the mean LOS (P = .010). Conclusion: Implementing EBPSC is a crucial step for improving the management of VOEs and creating a positive patient experience. The intervention enhances the quality of care for the SCD population in a UC center.
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Abstract
Acute vaso-occlusive crisis (VOC) is a hallmark of sickle cell disease (SCD). Multiple complex pathophysiological processes can result in pain during a VOC. Despite significant improvements in the understanding and management of SCD, little progress has been made in the management of pain in SCD, although new treatments are being explored. Opioids and non-steroidal anti-inflammatory drugs (NSAIDs) remain the mainstay of treatment of VOC pain, but new classes of drugs are being tested to prevent and treat acute pain. Advancements in the understanding of the pathophysiology of SCD and pain and the pharmacogenomics of opioids have yet to be effectively utilized in the management of VOC. Opioid tolerance and opioid-induced hyperalgesia are significant problems associated with the long-term use of opioids, and better strategies for chronic pain therapy are needed. This report reviews the mechanisms of pain associated with acute VOC, describes the current management of VOC, and describes some of the new therapies under evaluation for the management of acute VOC in SCD.
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22
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Adjemian R, Moradi Zirkohi A, Coombs R, Mickan S, Vaillancourt C. Are emergency department clinical pathway interventions adequately described, and are they delivered as intended? A systematic review. International Journal of Care Coordination 2017. [DOI: 10.1177/2053434517732507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction The accurate reproduction of clinical interventions and the evaluation of provider adherence in research publications improve the evaluation and implementation of research findings into clinical practice. We sought to examine the proportion of clinical pathway publications in an emergency department setting that adequately reported the following: (1) the exact reproduction of the clinical pathway that was implemented in the study, (2) the adherence to and correct execution of the clinical pathway intervention, and (3) the presence of a pre-implementation education phase. Methods We performed a descriptive systematic review of the literature from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. Validated clinical pathway criteria were used to identify relevant publications. Two reviewers independently collected data using a piloted data abstraction tool. Risk of bias was assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Tool and the Newcastle-Ottawa Scale. Results We identified 5947 publications, 44 of which met our inclusion criteria. The formal clinical pathway was fully reproduced in 27 (61%) publications, partially reproduced in 9 (21%), and not reproduced in 8 (18%). Only 14 (32%) studies reported whether at least one decision step was executed correctly. The presence of a pre-implementation education phase was reported in 33 (75%) studies. Conclusion The underreporting of intervention elements may present a barrier to both the evaluation and accurate replication of clinical pathway interventions. These finding may be useful for the elaboration of complex intervention reporting guidelines, improved reporting in future clinical pathway publications, and improved knowledge translation and exchange of clinical pathway interventions.
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Affiliation(s)
- Raffi Adjemian
- Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, Oxford, UK
- Department of Family Medicine, McGill University, Quebec, Canada
| | | | - Robin Coombs
- Department of Family Medicine, McGill University, Quebec, Canada
| | - Sharon Mickan
- Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Gold Coast Health, Griffith University, Gold Coast, Australia
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Baddam S, Aban I, Hilliard L, Howard T, Askenazi D, Lebensburger JD. Acute kidney injury during a pediatric sickle cell vaso-occlusive pain crisis. Pediatr Nephrol 2017; 32:1451-1456. [PMID: 28238158 PMCID: PMC5482758 DOI: 10.1007/s00467-017-3623-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 01/23/2017] [Accepted: 02/03/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients who develop sickle cell disease (SCD) nephropathy are at a high risk for mortality. The pathophysiology of vaso-occlusive pain crisis may contribute to acute kidney injury (AKI). Non-steroidal anti-inflammatory drugs, known inducers of AKI, are used to treat pain crises. Multiple gaps exist in the knowledge about the impact of AKI in SCD. METHODS We conducted a 2-year retrospective review of AKI events in patients admitted for vaso-occlusive crisis. AKI was defined by an increase of ≥0.3 mg/dL or 50% in serum creatinine from baseline. Laboratory values and ketorolac administration by days and dose (mg/kg) were identified from hospital records. A generalized mixed effects model for binary outcomes evaluated AKI based on laboratory variables and ketorolac administration. A generalized mixed Poisson effects model analyzed the association of AKI with hospital length of stay. RESULTS Thirty-three out of 197 admissions for vaso-occlusive pain crisis (17%) were associated with AKI. Fifty-two percent of the cases presented to the Emergency Room (ER) with AKI. Every one unit decrease in hemoglobin from baseline to admission increased the risk of AKI by 49%. Among patients who received ketorolac for pain, both total days and doses of ketorolac were associated with AKI. Finally, patients with pain and AKI required longer periods of hospitalization than patients without AKI. CONCLUSION Acute kidney injury during sickle cell pain crisis is common and may be an important modifiable risk factor for developing chronic kidney disease (CKD). Further studies are needed to determine the impact of nephrotoxic medications on progressive SCD nephropathy.
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Affiliation(s)
- Sujatha Baddam
- University of Alabama at Birmingham, Pediatric Hematology and Oncology
| | - Inmaculada Aban
- University of Alabama at Birmingham, Department of Biostatistics
| | - Lee Hilliard
- University of Alabama at Birmingham, Pediatric Hematology and Oncology
| | - Thomas Howard
- University of Alabama at Birmingham, Pediatric Hematology and Oncology
| | - David Askenazi
- University of Alabama at Birmingham, Pediatric Nephrology
| | - Jeffrey D Lebensburger
- Pediatric Hematology and Oncology, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder 512, Birmingham, AL, 35233, USA.
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Cloutier RL, Mistry RD, Cico S, Merritt C, Lam SHF, Auerbach M, Skaugset LM, Klig J, Wolff M, Duong M, Walthall J. Keeping Up With the Kids: Diffusion of Innovation in Pediatric Emergency Medicine Among Emergency Physicians. Acad Emerg Med 2017; 24:769-775. [PMID: 28421650 DOI: 10.1111/acem.13185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert L. Cloutier
- Emergency Medicine and Pediatrics; Oregon Health & Science University; Portland OR
| | - Rakesh D. Mistry
- Pediatrics and Emergency Medicine; University of Colorado School of Medicine; Section of Emergency Medicine; Children's Hospital Colorado; Aurora CO
| | - Stephen Cico
- Clinical Emergency Medicine & Pediatrics; Indiana University School of Medicine; Riley Hospital for Children; Indianapolis IN
| | - Chris Merritt
- Emergency Medicine & Pediatrics; Alpert Medical School of Brown University; Providence RI
| | - Samuel H. F. Lam
- UC San Diego Medical Center/Rady Children's Hospital of San Diego; San Diego CA
| | - Marc Auerbach
- Pediatrics and Emergency Medicine; Yale University School of Medicine; New Haven CT
| | | | - Jean Klig
- Pediatrics, Harvard Medical School/Massachusetts General Hospital; Boston MA
| | - Meg Wolff
- Emergency Medicine and Pediatrics; University of Michigan Medical School; Ann Arbor MI
| | - Myto Duong
- Pediatric Emergency Medicine; Southern Illinois University; Carbondale IL
| | - Jennifer Walthall
- Departments of Pediatrics and Emergency Medicine; Indiana University School of Medicine; Riley Hospital for Children; Indianapolis IN
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Adjemian R, Zirkohi AM, Coombs R, Mickan S, Vaillancourt C. Validation of descriptive clinical pathway criteria in the systematic identification of publications in emergency medicine. International Journal of Care Coordination 2017. [DOI: 10.1177/2053434517707971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Heterogeneity in both the definition and terminology of clinical pathways presents a challenge to the systematic identification of primary studies for review purposes. Recently developed clinical pathway identification criteria may facilitate both the identification and assessment of clinical pathway studies. The goal of this publication is the validation of these five criteria in a descriptive systematic review of actively implemented clinical pathway studies in the emergency department setting. The main outcome measure is the inter-rater agreement of investigators using the clinical pathway criteria. Methods We performed a systematic literature search from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. We identified relevant publications using the above-mentioned clinical pathway criteria. Two reviewers independently collected data using a piloted data abstraction tool. Results We identified 5947 publications, with 472 potentially relevant full text publications retrieved. Of these, 357 did not meet preliminary study inclusion criteria, leaving 115 publications where the clinical pathway criteria were applied. Ultimately, 44 publications were included. The inter-rater agreement of the criteria was very good (κ = 0.81, 95% Confidence Interval = 0.70–0.92). The vast majority of studies were excluded because the intervention did not meet the criterion of being multidisciplinary in nature. Conclusion These criteria are a useful instrument to reliably identify clinical pathway publications for systematic review purposes in an emergency department setting. Future modification of these criteria may improve their usefulness. Particular attention should be placed on clarifying what is meant by multidisciplinary involvement within the context of clinical pathway interventions, with specific emphasis placed on delineating the level of involvement of each discipline and their decision-making responsibility.
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Affiliation(s)
| | | | | | - Sharon Mickan
- University of Oxford, UK
- Griffith University, Australia
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26
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Inoue S, Khan I, Mushtaq R, Sanikommu SR, Mbeumo C, LaChance J, Roebuck M. Pain management trend of vaso-occulsive crisis (VOC) at a community hospital emergency department (ED) for patients with sickle cell disease. Ann Hematol 2015; 95:221-5. [PMID: 26611852 DOI: 10.1007/s00277-015-2558-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/11/2015] [Indexed: 11/30/2022]
Abstract
Pain management at the emergency department (ED) for vaso-occulsive crisis (VOC) for patients with sickle cell disease has not been optimum, with a long delay in giving the initial analgesic. We conducted a retrospective survey over a 7-year period to determine our ED's timing in giving pain medication to patients with VOC as a quality improvement project. We compared different periods, children vs adults, and the influence of gender in the analgesic administration timing. This is a retrospective chart review of three different periods: (1) years 2007-2008, (2) years 2011-2012, and (3) year 2013. We extracted relevant information from ED records. Data were analyzed using Student t test, chi-square analysis, and the Kruskal-Wallis test. There was a progressive improvement in the time interval to the 1st analgesic over these three periods. Children received analgesics more quickly than adults in all periods. Male adult patients received pain medication faster than female adult patients, although initial pain scores were higher in female than in male patients. Progressively fewer pediatric patients utilized ED over these three periods, but no difference for adult patients was observed. The proportion of pediatric patients admitted to the hospital increased with each period. The progressive decrease in both the number of patients and the number of visits to the ED by children suggested that the collective number of VOC in children has decreased, possibly secondary to the dissemination of hydroxyurea use. We failed to observe the same trend in adult patients. The need for IV access, and ordering laboratory tests or imaging studies tends to delay analgesic administration. Delay in administration of the first analgesic was more pronounced for female adult patients than male adult patients in spite of their higher pain score. Health care providers working in ED should make conscious efforts to respect pain in women as well as pain in men. Though not proven from this study, we believe that a significantly wider use of hydroxyurea by adult patients most likely would reduce their utilization of ED for the purpose of relief of pain, and further pediatric hematologists may be better positioned to increase hydroxyurea adherence by young adult patients, since they have had established rapport with them before transitioning to adult care.
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Affiliation(s)
- Susumu Inoue
- Department of Pediatric Hematology/Oncology, Hurley Children's Hospital, Flint, MI, 48503, USA.
| | - Isra'a Khan
- Community Hospital North, Community Health Network, Indianapolis, IN, USA.
| | - Rao Mushtaq
- Wake Forest Baptist Medical Center, Wake Forest University, Winston Salem, NC, USA.
| | | | - Carline Mbeumo
- Department of Pediatrics, Hurley Children's Hospital, Flint, MI, 48503, USA.
| | - Jenny LaChance
- Department of Research, Hurley Medical Center, Flint, MI, 48503, USA.
| | - Michael Roebuck
- Department of Emergency Medicine, Hurley Medical Center, Flint, MI, 48503, USA.
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