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Pain management in adult patients with sickle cell disease in the emergency department: how does current practice compare with existing standards of care?

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Abstract

Purpose

Sickle cell disease (SCD) is an inherited blood disorder with a natural course punctuated by acute complications including painful vaso-occlusive episodes. The objectives were: (1) to determine what proportion of patients with SCD receive opioids within 30 min of triage as recommended by the current clinical recommendations and quality standard; and (2) to identify facilitators to timely opioid administration for patients with SCD.

Methods

This was a retrospective observational study. The primary outcome was the proportion of visits in which patients received opioid analgesia within 30 min of triage. Secondary outcomes were time in minutes from triage to any analgesic administration and time from triage to first opioid administration. Patient demographics and ED encounter characteristics were included as potential associated variables.

Results

There were 236 patient visits (by 103 patients) that met inclusion criteria. Patients received opioid analgesia within 30 min of triage in only 5.2% of visits. The median time from triage to opioid analgesia was 80 (IQR = 49.0, 125.5) minutes. Using an order set and receiving opioid analgesia prior to physician assessment were both associated with shorter times to opioid analgesia.

Conclusion

Existing recommendations are that opioid analgesia be provided within 30 min of triage for patients with SCD and VOEs. Our data show this target is rarely met, even in a department in which SCD VOEs are a common presenting concern. The association of earlier opioid analgesia with order set use and administration prior to physician assessment highlights potential avenues for improving time to analgesia.

Résumé

Objectif

La drépanocytose (ou l'anémie falciforme) est une maladie héréditaire du sang dont l'évolution naturelle est ponctuée de complications aiguës, notamment des épisodes vaso-occlusifs douloureux. Les objectifs étaient : (1) de déterminer quelle proportion de patients atteints de drépanocytose reçoivent des opioïdes dans les 30 minutes suivant le triage, comme le recommandent les recommandations cliniques et la norme de qualité actuelles ; et (2) d'identifier les facteurs facilitant l'administration rapide d'opioïdes aux patients atteints de drépanocytose.

Méthodes

Il s'agissait d'une étude observationnelle rétrospective. Le critère de jugement principal était la proportion de visites au cours desquelles les patients ont reçu une analgésie opioïde dans les 30 minutes suivant le triage. Les critères de jugement secondaires étaient le temps en minutes écoulé entre le triage et l'administration de tout analgésique et le temps écoulé entre le triage et la première administration d'opioïdes. Les caractéristiques démographiques des patients et les caractéristiques des rencontres aux urgences ont été incluses comme variables potentiellement associées.

Résultats

Il y a eu 236 visites de patients (par 103 patients) qui répondaient aux critères d'inclusion. Les patients ont reçu une analgésie opioïde dans les 30 minutes suivant le triage dans seulement 5,2 % des visites. Le temps médian écoulé entre le triage et l'analgésie opioïde était de 80 (IQR = 49,0, 125,5) minutes. L'utilisation d'un ensemble de commandes et la réception d'une analgésie opioïde avant l'évaluation du médecin étaient toutes deux associées à des temps plus courts d'analgésie opioïde.

Conclusions

Les recommandations existantes sont que l'analgésie opioïde soit fournie dans les 30 minutes suivant le triage pour les patients atteints de drépanocytose et d'EVO. Nos données montrent que cet objectif est rarement atteint, même dans un service où les EVO de la drépanocytose sont une préoccupation courante. L'association d'une analgésie opioïde plus précoce avec l'utilisation d'un ensemble de commandes et l'administration avant l'évaluation du médecin met en évidence des pistes potentielles pour améliorer le temps d'analgésie.

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Data availability

The data that support the findings of this study are available on request from the corresponding author, JB within the limits of the project’s research ethics board waiver.

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Acknowledgements

We thank the Sickle Cell Awareness Group of Ontario, the Sickle Cell Association of Ontario, the University Health Network Emergency Department Quality Improvement Committee (especially Dr. Joseph Choi), the University Health Network Emergency Department Sickle Cell Working Group and the University Health Network Red Blood Cell Disorders Clinic for their advice and expertise in completing this work, and Dr. Alex Kiss for his biostatistical expertise. The authors would also like to acknowledge the Black Physicians Association of Ontario for their role in connecting physicians, patients, and community members for the advancement of care for those living with sickle cell disease.

University Health Network Emergency Department Sickle Cell Working Group: Lame Tunji-Ajayi, Serena Thompson, Ruth Appiah-Boateng, Jennifer Bryan, Kaitlin Azubuike, Ulysse Guerrier, Markus Gulilat, Jennifer Hulme, Lance Armstrong, Marie-Pascale Poku, Karen Fleming, Nia Navarro, Hasan Sheikh, Tricia Williams, Betty Lulseged.

Funding

This work was funded by the University Health Network Physician Council on Quality and Safety and the University Health Network Summer Training and Research in Emergency Medicine (STAR-EM) program. This manuscript is the work of the authors and not their institutions.

Author information

Authors and Affiliations

  1. Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada

    Markus Gulilat

  2. Sickle Cell Awareness Group of Ontario, Toronto, ON, Canada

    Lanre Tunji-Ajayi & Marie-Pascale Poku

  3. University Health Network, Toronto, ON, Canada

    Ruth Appiah-Boateng, Nia Navarro, Hasan Sheikh, Jennifer Hulme & Jennifer Bryan

  4. Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

    Hasan Sheikh & Jennifer Hulme

  5. Department of Medicine, University of Toronto, Toronto, ON, Canada

    Jennifer Bryan

  6. Patient Advocate, Toronto, ON, Canada

    Serena Thompson

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  1. Markus Gulilat
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Consortia

The University Health Network Emergency Department Sickle Cell Working Group

  • Lanre Tunji-Ajayi
  • , Serena Thompson
  • , Ruth Appiah-Boateng
  • , Jennifer Bryan
  • , Kaitlin Azubuike
  • , Ulysse Guerrier
  • , Markus Gulilat
  • , Jennifer Hulme
  • , Lance Armstrong
  • , Marie-Pascale Poku
  • , Karen Fleming
  • , Nia Navarro
  • , Hasan Sheikh
  • , Tricia Williams
  •  & Betty Lulseged

Corresponding author

Correspondence to Jennifer Bryan.

Ethics declarations

Conflict of interest

MG declares that he has no conflict of interest. LTA has received research grants/funding/honoraria from the Public Health Agency of Canada/is a consultant with Novartis Inc and Roche Inc. ST has received research grants/funding/honoraria from/is a member of Healthcare Excellence Canada. MPP declares that she has no conflict of interest, RAB declares that she has no conflict of interest. NN declares that she has no conflict of interest, HS declares no conflict of interest. JH is the director of the University of Toronto Global Health Emergency Medicine and receives a stipend from the UHN Emergency Department as an Equity co-lead, JB is the chair of the Canadian Association of Emergency Physicians Committee on Antiracism and Anticolonialism and is a Canadian Association of Emergency Physicians equity, diversity, and inclusion advisor.

Additional information

Communicated by Catherine Varner.

The members of the instutional author group “the University Health Network Emergency Department Sickle Cell Working Group” was processed under acknowledgements section.

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Gulilat, M., Tunji-Ajayi, L., Thompson, S. et al. Pain management in adult patients with sickle cell disease in the emergency department: how does current practice compare with existing standards of care?. Can J Emerg Med 25, 836–844 (2023). https://doi.org/10.1007/s43678-023-00579-y

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