Background: Adults with sickle cell disease (SCD) often present with extremely painful acute vaso-occlusive crises (VOC). VOC guidelines quote studies supporting early initiation of opioids, but are lacking in a standardized approach to achieve adequate analgesia and subsequent de-escalation. Various SCD studies comparing continuous basal versus demand bolus patient-controlled analgesia (PCA) show conflicting outcomes. Thus the objective of our pilot was to develop a standardized approach to pain management utilizing PCA and a Tiered Oral Therapy Protocol (TOTP) in an effort to affect healthcare utilization by decreasing length of stay without increasing readmission rates. Methods: We studied admissions of 31 SCD (any genotype) patients (8 males, 23 females) ≥ 18 years old, all African-American, admitted for VOC, and treated by hospitalist providers using TOTP on one medical unit at Virginia Commonwealth University Health System from July 2018 to June 2019. Inpatient admissions for one calendar year prior to the initial TOTP admission served as the patient's historical control. TOTP is guided by the patient's individualized treatment plan and starts with continuation of their home basal dosing, demand dose only PCA, and immediate-release oral opioids for additional breakthrough pain. TOTP goals are aggressive up-titration of opioids until adequate analgesia. After a period of stability the next phase encourages timely, aggressive down-titration of opioids to speed discharge. We primarily compared length of stay (LOS), hospital charges, and 30-day readmission rates for TOTP vs historical controls. Secondarily, we compared adverse safety events: opioid-related rapid responses, naloxone administration, or falls. Results: Utilization of TOTP resulted in reductions in LOS (21%, 4.7 days controls vs. 3.7 days TOTP, p<0.014), and hospital charges ($1,627,497.73 controls vs. $944,528.96 TOTP, p=0.1403), and an insignificant increase in the 30-day readmission rate (35.6% controls vs. 42.7% TOTP, p=0.5027). Hospital charge data is difficult to interpret as a full year of post TOTP encounters are not available for all patients. There were no TOTP vs. historical control differences in opioid-related safety events. Conclusion: Standardization of therapy using the TOTP improved length of stay and reduced charges for patients with sickle cell disease admitted for acute VOC without increasing adverse safety events or significantly impacting the 30 day readmission rate. We have enlarged this pilot to include other VCU medical units, to test whether we can reproduce our initial one-unit success. Further, we recommend TOTP implementation and testing in other hospitals to exclude secondary trends, since TOTP was but one among several interventions in a VCU Adult SCD Medical Home. Figure Disclosures Smith: Novartis: Consultancy, Honoraria.
Introduction: Sickle cell disease (SCD) vaso-occlusive crisis (VOC) often requires hospitalization, but SCD pain may be present prior to admission and persist past discharge, similar to many acute-on-chronic painful conditions. In practice, readiness for discharge during VOC is a judgment and/or negotiation between patients and their caregivers. Subjective pain intensity, rated on a unidimensional continuous or numeric rating scale, communicates neither readiness for discharge, nor patients' multidimensional pain experience. Inpatient multidimensional pain scales that incorporate concepts like physical function may require too much time and/or impose a high, daily respondent burden on uncomfortable SCD respondents. We found no well-established brief daily adult inpatient multidimensional assessment scale for SCD, but found a pediatric daily function SCD scale, as well as scales used in systemic lupus erythematous and fibromyalgia. We therefore developed and validated the functional status-based pain-assessment (FSPA) survey meant to improve evaluation of readiness for discharge during VOC. Methods: FSPA was created using concepts from the above scales, plus input from inpatient management experts familiar with SCD, including physicians, nurse practitioners, pharmacists, and bedside nurses. FSPA helps assess the full spectrum of a patient's functional limitations due to pain. FSPA consists of tasks that are recorded using the patient's self-reported ability (5 point Likert scale ranging from "very easy" to "very difficult") to complete activities including sleeping, watching TV, walking around the room, or eating a meal in a chair. FPSA was designed to be on a health literacy grade of one. Patients were asked to complete FSPA daily at approximately the same time of day. Concurrently, they were asked to rate their pain using a Numeric Rating Scale (NRS, 0-10). Surveys were administered on a preselected nursing unit from January 2018 to June of 2019. Means (standard deviations) or frequencies were used to summarize data. Pearson's correlation was used to examine the relationship between the two continuous variables. Believing readiness for discharge to be a single factor, we performed confirmatory factor analysis (CFA) using structural equation modeling for determining the empirical validity of having a one-factor solution for the FSPA tool. We used item response theory analysis to determine the characteristics of each item using graded response model within a 2-parameter framework. All analyses were performed using Stata 14.0. Results: During the study period, 504 assessments from 86 unique patients over 170 distinct admissions were completed. Of the 86 unique patients, 54% were females with mean age of 31.5 (SD8.0) years. The length of stay was 7.1 (SD6.9) days; minimum 0 days, max 38 days. NRS mean was 6.8 ±1.9 and FSPA mean was 27±8.0. Correlation was moderate and highly significant (Pearson's r = -.4342, p <.0001). The CFA indicated that the one-factor structure was a good fit for the data using routine diagnostic statistics (Figure). Using item response theory analysis, we found that the item discrimination varied from 0.56 to 4.1 while difficulty of the items covered broadly the latent variable of the functional status with pain with values ranging from -2.8 to 7.5. Conclusions: Development and validation of FPSA, while not complete, has yielded a brief assessment tool which may be used daily to improve communication between adult SCD VOC patients and their inpatient clinicians. FPSA may aid the judgment and negotiation of readiness for discharge of these patients, in order to prevent unnecessarily short or long hospital lengths of stay as well as improve patient and provider satisfaction. Future validation could compare FSPA to other longer-term pain and functional assessment tools, determine its ability to predict VOC discharge, and determine whether its use changes VOC discharge behavior. Figure Disclosures Smith: Novartis: Consultancy, Honoraria.
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