Day case management of sickle pain: 3 years experience in a UK sickle cell unit

A day centre was established to determine whether an alternative approach to the management of uncomplicated sickle pain would improve the quality of care and reduce hospital admissions in patients with sickle cell disease. Since the centre opened there has been a 43% decrease in hospital admissions and 49% decrease in occupied bed days. In the third year, 84% of patients treated for severe sickle pain were managed without the need for hospital admission. A centre offering day case management of painful crisis reduced unnecessary hospital admissions for uncomplicated pain. This approach is safe and cost-effective.     

Adult Sickle Cell Disease Epidemiology and the Potential Role of a Multidisciplinary Comprehensive Care Center in a City with Low Prevalence

The aim of this study was to determine the characteristics of the sickle cell disease population in a city of low prevalence and compare them to those reported in the literature. We performed a retrospective cross-sectional study of all sickle cell disease patients seen in the Calgary Health Region, Calgary, Alberta, Canada from 2006 to 2010. Data on clinical endpoints including emergency department (ED) visits, hospital admissions, transfusions, as well as laboratory parameters were collected. A total of 37 adult sickle cell disease patients were identified. Over 5 years, they were represented by a total of 49.2 ED presentations/year, 29.2 (59.0%) of these requiring admission. Eighty-three percent of these presentations were for acute pain episodes. We concluded that the number of ED visits, hospital admissions and several other parameters in our cohort were similar to those in other centers of higher prevalence. This suggests that guidelines representing regions of high prevalence may be applicable to smaller centers, where patients experience similar clinical outcomes.     

Oral analgesia for treatment of painful crisis in sickle cell anemia

A therapeutic plan that emphasized oral narcotic analgesia was instituted for the treatment of painful crisis of sickle cell anemia. Of the 100 adult sickle cell syndrome patients registered at North Central Bronx Hospital, 15 were identified as using the emergency department facilities three or more times per year. This "frequent user" patient population was tracked in their hospital and drug usage patterns during the first full year of the oral protocol and compared to their own patterns during the year prior to the protocol. The patients used the ED at the same rate but their frequency of admissions to the hospital dropped by 75%. The oral program produced a significant fall in the amount of narcotics dispensed in the ED (P less than .01).     

Inpatient telemetry does not need to be used in the management of older patients hospitalized with chest pain at low risk for in-hospital coronary events and mortality

BACKGROUND: Little is known about patients admitted with chest pain to inpatient telemetry units directly from an emergency department. METHODS: We analyzed data from 105 consecutive patients who presented with chest pain to an emergency department and who were hospitalized in an inpatient telemetry unit but who were at low risk for a coronary event. RESULTS: Telemetry yielded no information which was used to manage any patient. None of the 105 patients (0%) developed a myocardial infarction or died during hospitalization. At 4.8-year follow-up, 8 of 105 patients (8%) died. Significant risk factors for long-term mortality were age (p < .001), prior coronary artery disease (p < .05), and diabetes (p < .02). CONCLUSIONS: Inpatient telemetry was of no value in predicting short-term coronary events or mortality or long-term mortality in low-risk patients hospitalized with chest pain.     

Update on pain management in sickle cell disease

Acute pain is the hallmark of sickle cell disease and is the most common cause of hospital admissions. Tissue damage due to vaso-occlusion releases numerous inflammatory mediators that initiate the transmission of painful stimuli that culminate in the perception of pain. The acute sickle cell painful crisis evolves along four phases. Each phase is coupled with changes in certain markers of the disease. Hospital readmission occurs within 1 week in about 16% of discharged patients and within 1 month in about 50% of discharged patients. Failure to treat acute pain aggressively may lead to chronic pain syndrome which, in turn, initiates neuropathic pain. Management of sickle pain is primarily pharmacological in nature and opioids are the analgesics used most often. Adverse effects of opioids include histaminergic, excitatory, dopaminergic and proserotonergic effects. Cellular and molecular mechanisms of opioids explain individual differences among patients and justify the use of individualized treatment plans.     

Usefulness of empiric chest radiography and urinalysis testing in adults with acute sickle cell pain crisis

STUDY OBJECTIVE: To determine the usefulness of obtaining routine chest radiographs and urinalyses on adults presenting to the emergency department in acute sickle cell pain crisis. The hypothesis tested is that in some adult sickle cell patients, sickle cell pain crises are precipitated or accompanied by acute infection that may be clinically occult and that routine screening for pulmonary or urinary tract infection would identify some of these precipitating illnesses. DESIGN: Prospective clinical study. SETTING: A university hospital ED. PATIENTS: All patients more than 14 years old with S-S, S-C, or S-beta-thalassemia sickle hemoglobinopathies who presented to the ED with acute nontraumatic painful complaints during a six-month period. INTERVENTIONS: All patients underwent posteroanterior and lateral chest radiography, routine urinalysis, and CBC count with reticulocyte count. A standard questionnaire for localizing symptoms of systemic, pulmonary, and urinary tract infection was completed for each patient. Urine cultures were ordered on all patients with voiding symptoms, flank pain, and/or more than 5 WBCs or RBCs per high-power field on urinalysis. Physical examination for evidence of pulmonary and urinary tract infection was carefully performed and recorded for subsequent analysis. RESULTS: Seventy-one patients with 134 ED presentations were studied over a six-month period. Eight diagnoses of acute pneumonia were made. Four of these patients complained of chest pain (50% vs 48% overall) and three had shortness of breath (38% vs 21%). None of these patients complained of fever or symptoms of upper respiratory illness. Ten diagnoses of urinary tract infection were made. Four of these patients complained of dysuria and frequency; three complained of flank pain. Eleven of the 18 infections (61.1%) did not have a typical history for or suggestive physical or laboratory findings of bacterial infection. CONCLUSION: In sickle cell disease patients with pain crisis, routine chest radiography and urinalysis may be clinically useful and cost effective in the early diagnosis of crisis-related infection.     

Opioid management and dependency among adult patients with sickle cell disease

While pain is one of the most debilitating symptoms of sickle cell disease, narcotics remain an effective although controversial widely practiced intervention. Vaso-occlusive crises are the most common cause for seeking pharmacological treatment. The influence of stigmatization and pseudo addiction in emergency departments and outpatient clinics was reviewed. We analyzed patterns of narcotic utilization in a sample of 63 adult patients with sickle cell disease to determine if their psychological functioning and reports of pain differed as a function of the primary narcotics they were taking for oral pain management. Fifty-one percent of patients reported treatment of Oxycodone, 35% OxyContin, 24% methadone and 11% morphine. Patients who were treated with Oxycodone reported greater sensory reactions to pain (p = 0.001), visual analog scale (VAS) (p = 0.02), and averaged weekly pain intensity ratings than patients who did not use this medication. There were no differences in pain or affective response in patients treated with OxyContin, methadone or morphine. We suggest there are clear differences between the reports of pain in patients with sickle cell disease taking short-acting narcotics for pain management as compared to those who are not, a pattern that does not distinguish patients who are managed with long-acting preparations. We discuss the relevance of addressing narcotic management in the context of the perception of health care providers and patients with sickle cell disease.     

Chest pain unit concept: rationale and diagnostic strategies

Each year in the United States, over 8 million patients present to the emergency department(ED) with complaints of chest discomfort or other symptoms consistent with possible acute coronary syndrome (ACS). While over half of these patients are typically admitted for further diagnostic evaluation, fewer than 20% are diagnosed with ACS.With hospital beds and inpatient resources scarce, these admissions can be avoided by evaluating low- to moderate-risk patients in chest pain units. This large, undifferentiated patient population represents a potential high-risk group for emergency physicians requiring a systematic approach and specific ED resources. This evaluation is required to appropriately determine if a patient is safe to be discharged home with outpatient follow-up versus requiring admission to the hospital for monitoring and further testing.     

Long-term survival of emergency department patients with acute chest pain.

To evaluate the long-term prognosis of patients with acute chest pain, prospective clinical data and long-term follow-up data (mean 30.1 +/- 9.4 months) were collected for 1,956 patients who presented to the emergency department of an urban teaching hospital with this chief complaint. During follow-up of the 1,915 patients who were discharged alive from the emergency department or hospital, there were 113 (6%) cardiovascular deaths. No differences were detected in the post-discharge cardiovascular survival rates after 3 years of experience with patients who were discharged from the emergency department with a known prior diagnosis of angina or myocardial infarction (89%) and patients who had been admitted and found to have acute myocardial infarction (85%), angina (87%), or other cardiovascular diagnoses (87%). Patients who were discharged from either the hospital or the emergency department without cardiovascular diagnoses had an excellent prognosis. Multivariate Cox regression analysis identified 5 independent correlates of cardiovascular mortality after discharge: age, prior history of coronary disease, ischemic changes on the emergency department electrocardiogram, congestive heart failure and cardiogenic shock. These findings indicate that the postdischarge cardiovascular mortality of patients with chest pain who are discharged from the emergency department with a known history of coronary disease is similar to that of admitted patients with angina or myocardial infarction. These data suggest that the same types of prognostic evaluation strategies that have been developed for admitted patients with ischemic heart disease should also be considered when such patients present to the emergency department but are not admitted.     

The Effect of Hydroxyurea Therapy in Bahraini Sickle Cell Disease Patients

Hydroxyurea (HU) is used as a disease-modifying agent in sickle cell disease (SCD). Its beneficial effects have been ascribed to inhibition of the sickling process through increase of fetal hemoglobin (HbF) levels and influence on multiple factors affecting adhesion of erythrocytes to vascular endothelium. The present study investigates the effect of HU in SCD patients who were grouped on the basis of association with α- and β-thalassemia using routine laboratory methods. A retrospective cross-sectional chart-review was done of 51 adult Bahraini SCD patients attending Salmaniya Medical Complex, Bahrain. Four sub-groups of cases were identified: (i) homozygous sickle cell anemia, 24 cases; (ii) SCD with microcytosis, 16 cases; (iii) sickle α-thalassemia, seven cases; and (iv) sickle β thalassemia, four cases. Documented laboratory and clinical data included hemoglobin level (Hb), hematocrit (Hct), red cell indices, hemoglobin fractions, hospital admissions (frequency), number of inpatient-days, pain episodes (frequency) and red cell transfusion requirement (number of units). Pre- and post-treatment data were compared. Hydroxyurea treatment led to highly significant reduction of HbS % and pain crisis episodes in all patient groups. Other changes such as increases of total hemoglobin, Hct and HbF and reduction of hospital admissions, inpatient days and red cell units transfused also occurred but with less consistent levels of significance within patient sub-groups. Treatment with HU is beneficial for all subgroups of Bahraini SCD patients, without or with α- and β-thalassemia interactions.     

Emergency Department Observation Unit: Can It Be Funded Through Reduced Inpatient Admission?

Study objective: We sought to test the assumption that an emergency department observation unit can be funded through the reallocation of resources made available through the unit’s impact in reducing inpatient admissions and facilitating bed closures. Methods: We conducted our study in a tertiary care center ED with 46,000 visits annually. For a 3-month period, all patients admitted to the hospital through the ED were screened by an emergency physician for suitability for admission to an observation unit. Any patient in the hospital for 3 days or less who did not undergo surgery or other inpatient procedure, and who was admitted through the ED, was considered a candidate for the observation unit. Results: Of 1,840 admissions, 147 patients met the admission criteria. Only 48 (32.2%) could have been treated in an observation unit, and these patients were not admitted to any single unit in high frequency. The potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents—not enough to staff a 4-bed observation unit, which would require 5 full-time equivalents. Conclusion: Because of the diffuse and inconsistent effect such a unit had on inpatient bed use, funding for an ED observation unit at our institution could not be justified on the basis of the closure of inpatient beds and transfer of resources. [Sinclair D, Green R: Emergency department observation unit: Can it be funded through reduced inpatient admission? Ann Emerg Med December 1998;32:670-675.]     

Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises

Painful crisis episodes are poorly treated in sickle cell anemia, both in timeliness and appropriateness of care. Delayed treatment in Emergency Departments, unrelieved pain, frequent admissions, and prolonged hospitalizations are common. We established a Day Hospital (DH) to determine if an alternative care delivery system could improve pain relief and reduce unnecessary hospital admissions for patients with uncomplicated painful crises. Trained DH staff delivered prompt titration for pain relief based on each patient's analgesic history and qualitative and quantitative assessments. Response to therapy and comorbidities commanded disposition. During the first 5 years of DH operation there were 2554 visits; 60% of the patients had severe pain. During an average visit of 4.5 hours, 84% of the patients were titrated to relief; 90% had pain relief within 2 to 4 hours. Overall, 81% of the patients were discharged home (70% initially and 90% to 94% in the last 3 years). During the first 5 years of the DH, there were 2612 emergency department (ED) visits that averaged 13 hours each. The combined ED and DH admissions during this time represented a 40% decrease in the baseline ED admission rate of 92%, (1 year pre-DH). Patients with uncomplicated painful crisis were admitted 5 times less often from the DH (8.3%) than from the ED (42.7%). The length of stay (LOS) for inpatients followed by the DH staff decreased by 1.5 days, while the LOS for patients followed by non-DH staff remained unchanged. Reduction of admissions and LOS represented a savings of approximately $1.7 million. We conclude that a dedicated facility provides the kingpin for effective and rapid painful crisis management, reduces hospitalizations, and facilitates integration of the approach into other areas of care. (Blood. 2000;95:1130-1136)     

Chest pain in clinical practice: impact of routine troponin determination on clinical manifestations and care

INTRODUCTION AND OBJECTIVES. To study the significance of chest pain in the clinical practice of a Spanish hospital and to evaluate the impact of routine troponin determination. METHODS: In our institution, routine serial measurements of troponins I and T were made in the evaluation of chest pain in 2000. We compared the results obtained in 1999 for all patients who visited the emergency room for chest pain and the patients who were hospitalized. We recorded the diagnosis at discharge, duration of the hospital stay, and associated costs. RESULTS: In 2000, 1,820 patients with chest pain visited the emergency department, which was equivalent to 1.9% of visits and 7.5 cases per 1,000 people and year: 43% of these patients were hospitalized for suspected acute coronary syndrome as compared to 49% in 1999 (-12%; p > 0.001). Among the patients admitted, 28% were discharged with a diagnosis of non-ischemic chest pain. Troponin determinations were associated with a lower probability of admission due to unstable angina (11.5 vs 16.0%; -28%; p < 0.001) and non-ischemic chest pain (12.1 vs 14.5%; -16%; p < 0.05), and an increase in diagnoses of non-Q wave acute myocardial infarction (3.4% vs 1.8%; +89%; p < 0.01). Non-ST elevation acute coronary syndrome ACS required 3,751 days of hospitalization and 1,003,420 euros of cost, and troponin determinations were associated with a reduction in hospital stays of 832 days (-18.2%) and 185,100 euros (-15.6%). CONCLUSION: Chest pain had a high incidence, 7.5, and generates high costs in hospital admissions. The routine use of serial troponin determinations was associated with a reduction in hospital admissions due to unstable angina and non-ischemic chest pain, and costs.     

Ketorolac for sickle cell vaso-occlusive crisis pain in the emergency department: lack of a narcotic-sparing effect.

STUDY OBJECTIVE: To determine if a single dose of intramuscular ketorolac given on presentation to the emergency department has a narcotic-sparing effect in adult patients with sickle cell vaso-occlusive crisis pain. DESIGN: A prospective, randomized, single-dose, double-blind study. SETTING: ED of a university hospital and an affiliated county hospital. TYPE OF PARTICIPANTS: Eighteen adult patients who presented to the ED with sickle cell crisis pain a total of 24 times. INTERVENTIONS: Patients were randomized to receive either ketorolac 60 mg IM or placebo on presentation to the ED. Subjects were administered meperidine on presentation and then received a standardized dose of meperidine every 30 minutes during the four-hour observation period based on the severity of pain. MEASUREMENTS AND MAIN RESULTS: The 12 subjects in the ketorolac group received an average of 231 +/- 92 mg meperidine, whereas the 12 subjects in the placebo group received an average meperidine dose of 250 +/- 85 mg (P = .61). CONCLUSION: The use of intramuscular ketorolac did not lead to a clinically significant reduction in the requirement for narcotics during the four-hour ED treatment period.     

Pilot study of continuous co-infusion of morphine and naloxone in children with sickle cell pain crisis

Patients with sickle cell disease experience painful crises that often require hospitalization for a continuous infusion of morphine that may cause significant pruritus. We conducted a pilot study to determine the feasibility of simultaneous continuous co-infusion of naloxone with morphine, test novel assessment instruments for pruritus, and explore whether pruritus could be reduced while maintaining effective analgesia. Patients with sickle cell disease and painful crisis requiring continuous infusion morphine received continuous co-infusion of naloxone at 0.25 (low dose) or 1.0 mcg/kg x hr (high dose). Pain scores were obtained using the FACES scale and a 100-mm visual analog scale (VAS). Itching was quantified by a modified VAS score. Evaluable data were obtained on 16 patients. Simultaneous co-infusion of naloxone and morphine was feasible, did not seem to reduce the analgesic efficacy of morphine, and was associated with no adverse effects. The high dose group reported a lower median "VAS worst itch" score than the low dose group (4.8 vs. 7.3, P = 0.08). Simultaneous continuous infusion of naloxone with morphine in pediatric patients with sickle cell disease and pain crisis was feasible and well tolerated. A quantitative pruritus score allowed us to systematically measure pruritus. Further evaluation by randomized, placebo-controlled study of 1 mcg/kg x hr naloxone in this setting is required.     

Eliminating analgesic meperidine use with a supported formulary restriction

PURPOSE: Meperidine is a commonly used analgesic despite unique disadvantages compared with other opioid analgesics. The objective of this study was to measure the effects of a meperidine formulary restriction on the prescribing of parenteral opioid analgesics. MATERIALS AND METHODS: The study was performed at a single 750-bed tertiary care teaching hospital in Rochester, NY. The formulary restriction limited meperidine to use exclusively for rigors or procedural sedation and was supported by an educational initiative and a computerized order entry system. Independent computerized pharmacy records were used to capture all doses of parenteral morphine, meperidine, and hydromorphone administered to patients in the emergency department or on a medical or surgical inpatient floor during data-collection periods. Baseline data were collected during two 3-day periods before the formulary restriction; then comparison data were collected during three 3-day periods over 15 months after the formulary restriction. RESULTS: The number of administered doses of meperidine per day decreased from 37.5 (20.8% of parenteral opioid doses before the restriction) to 0.22 (0.1% of parenteral opioid doses, P = .001). The total number of opioid doses and morphine doses given did not change, whereas the number of hydromorphone doses increased significantly postrestriction, from 16.0 doses per day (8.9% of total) to 59.7 doses per day (29.5%) (P = .009). CONCLUSION: Meperidine formulary restriction, supported by an educational program and computerized order entry, effectively eliminated analgesic meperidine use. Hydromorphone use increased proportionately to offset the decreased use of meperidine.     

Cocaine-associated chest pain

STUDY OBJECTIVES: To describe the clinical and ECG features of cocaine abusers evaluated in the emergency department and admitted to the medical coronary care unit with chest pain consistent with myocardial ischemia. DESIGN: A four-month retrospective review of all cocaine abusers who presented to the ED with chest pain and a diagnosis of possible myocardial infarction. SETTING: Urban county hospital. TYPE OF PARTICIPANTS: Forty-eight adult cocaine abusers admitted with chest pain. MEASUREMENTS AND MAIN RESULTS: Patients included 34 men and 14 women with a mean age of 29 +/- 7.3 years. The average duration of cocaine abuse in 28 patients for whom it was reported was 5 +/- 4.8 years. Chest pain occurred within one hour of cocaine abuse in 13 admissions (27%), more than one hour after abuse in 13 admissions (27%), and it was not recorded in 23 admissions (47%). Initial ECGs were evaluated in all patients and revealed significant repolarization abnormalities consisting of abnormal ST segment elevations in 18 (37%) and T-wave inversions in 20 (41%) that often persisted on subsequent ECGs. Three patients sustained acute myocardial infarctions. CONCLUSIONS: Our findings confirm a small but significant incidence of myocardial infarction in cocaine abusers presenting to the ED with chest pain. The chronicity of cocaine abuse, the persistence of ECG abnormalities, and the variable temporal relationship of chest pain to cocaine abuse suggest possible chronic myocardial changes as etiologies of ischemia.     

Hypomagnesemia is a frequent finding in the emergency department in patients with chest pain

STUDY OBJECTIVE--To evaluate the frequency of low blood levels of total and ultrafilterable magnesium (total and ultrafilterable hypomagnesemia) in patients with chest pain in the emergency department, and to determine if hypomagnesemia is associated with other clinically important diagnostic and outcome variables in cardiac care. SETTING--An emergency department of a university teaching hospital. DESIGN--Prospective study of extracellular magnesium homeostasis in patients with chest pain in the emergency department and a cohort of patients without chest pain with a clinical indication for blood sampling. PATIENTS--During a 4-month period, 147 patients presenting to the emergency department were studied: 67 patients (mean +/- SD age, 61.4 +/- 13 years) with a chief complaint of chest pain (study group) and 80 patients (55.6 +/- 19 years) with other diagnoses (control group). RESULTS--Total and ultrafilterable hypomagnesemia occurred more frequently in patients with chest pain (20/67 [30%] and 9/67 [13%]) than in the control group (12/80 [15%] and 3/80 [4%]). Patients with a chief complaint of chest pain who were receiving diuretic medications were hypomagnesemic more frequently (9/16 [56%]) than patients not receiving diuretics (12/51 [23%]). In patients with chest pain admitted to the hospital with a diagnosis of "rule out" myocardial infarction, the frequency of hypokalemia was greater among hypomagnesemic patients (6/14 [43%]) than normomagnesemic patients (3/31 [10%]). A similar frequency of hypomagnesemia was noted in patients with a final diagnosis of myocardial infarction (4/15 [27%]) when compared with other patients admitted with chest pain (10/31 [32%]) in whom myocardial infarction was excluded. No association was noted among hypomagnesemia and length of hospital stay or the occurrence of hypotension or dysrhythmias. CONCLUSIONS--Total and ultrafilterable hypomagnesemia are frequent occurrences in patients with and without chest pain in the emergency department. Diuretic use is associated with hypomagnesemia in patients presenting with chest pain in the emergency department. These results support the concept that hypomagnesemia is common in patients with chest pain in the emergency department and is associated with hypokalemia but is not predictive of whether the patient with chest pain has had an acute myocardial infarction.     

Diagnostic value of anemia, red blood cell morphology, and reticulocyte count for sickle cell disease.

STUDY OBJECTIVE: To determine the diagnostic value of anemia, RBC morphology, and reticulocyte count for differentiating patients with sickle cell trait from those with sickle cell disease, who have acute medical or surgical conditions and a positive sickle cell screen. DESIGN: Retrospective chart review. SETTING: A midwest urban children's hospital with 220 beds and 36,000 emergency department visits per year. PARTICIPANTS: One hundred six patients with sickle cell trait and 152 patients with sickle cell hemoglobinopathies. RESULTS: Anemia was observed significantly more often in patients with sickle cell disease compared with sickle cell trait (P less than .001) at all ages 3 months and older. However, anemia alone as a diagnostic test lacked high sensitivity and specificity in children less than 4 years old. Sensitivity approached 100% with the presence of anemia, abnormal RBC morphology, or reticulocyte count of more than 2%. CONCLUSION: Absence of anemia alone does not exclude the diagnosis of sickle cell disease in children less than 4 years old. To differentiate trait from sickle cell disease, we recommend determination of not only hemoglobin adjusted for age but also of RBC morphology and reticulocyte count on all children presenting with acute medical and surgical conditions and a positive sickle cell screen.     

The observation unit: a new interface between inpatient and outpatient care

PURPOSE: Observation units for patients who present to emergency departments with chest pain have become common. We describe our 3-year experience with a multipurpose observation unit in which chest pain accounts for only a minority of patients' presenting clinical syndromes. SUBJECTS AND METHODS: We analyzed the effects of a 12-bed observation unit on inpatient admissions for common clinical syndromes, as well as its overall effects on inpatient medical admissions during its first 3 years of operation (1996 to 1998) compared with the 3 years preceding its creation (1993 to 1995). RESULTS: Among 7,507 patients admitted to the observation unit in 1996 to 1998, 6,334 (85%) were discharged home within 23 hours. Total inpatient medical admissions fell by a similar number (n = 5,366) during the 3 years of operation of the observation unit when compared with the 3 preceding years (39,569 admissions in 1996 to1998 versus 44,935 in 1993 to 1995). Analysis of local area trends suggested that the use of the observation unit contributed to reduced hospital admissions, rather than vice versa. CONCLUSION: Observation units can serve patients with diverse clinical syndromes and may reduce inpatient admissions. This novel "point of care" deserves further evaluation.