Use of a clinical pathway to improve the acute management of vaso‐occlusive crisis pain in pediatric sickle cell disease

Ender, Katherine L.; Krajewski, Jennifer; Babineau, John; Tresgallo, Mary; Schechter, William S.; Saroyan, John M.; Kharbanda, Anupam B.

doi:10.1002/pbc.24864

Cited by 31 publications

(35 citation statements)

References 30 publications

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“…Our post‐intervention admission rate of 41% is lower that what has been previously reported in the literature. Previous studies of VOC in children have reported admission rates between 50 and 78% . We estimate that 49 admissions and 307 inpatient days are avoided annually through the initiative.…”

Section: Discussionmentioning

confidence: 97%

“…We found the high admission rates for patients presenting with VOC both locally (50–57%) and nationally (50–78%) to be unacceptable. At our center, we observed an inconsistent approach to pain management both in the ED and after admission.…”

Section: Introductionmentioning

confidence: 84%

“…Several strategies have been attempted to reduce the burden of VOC through standardizing care. Standardized care pathways have previously been shown to improve time to first opiate dose, increased ketorolac use, and pain scores, but most have not reduced admission rate . Attempts have also been made to individualize care for these children.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department

Schefft

Swaffar

Newlin

et al. 2018

Pediatric Blood & Cancer

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Section: Discussionmentioning

confidence: 97%

Section: Introductionmentioning

confidence: 84%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department

Schefft

Swaffar

Newlin

et al. 2018

Pediatric Blood & Cancer

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“…A third concern for frequent NSAID use is that some pediatric SCD patients have CYP2C9 allele variants that alter NSAID metabolism and may place these patients at increased risk for NSAID toxicity [34]. A final issue relevant to inducing AKI is that ER and inpatient teams may initially manage patients with ketorolac as part of standardized clinical pain pathways or based on individual physician preference [35, 36]. Two randomized clinical trials failed to demonstrate that ketorolac can reduce hospital days, or total morphine dose [37, 38].…”

Section: Discussionmentioning

confidence: 99%

Acute kidney injury during a pediatric sickle cell vaso-occlusive pain crisis

et al. 2017

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Background Patients who develop sickle cell disease (SCD) nephropathy are at 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 knowledge about the impact of AKI in SCD. Methods We conducted a two year retrospective review of AKI events in patients admitted for vaso-occlusive crisis. AKI was defined by an increase by ≥0.3 mg/dl or 50 % increase in serum creatinine from baseline. Laboratory values and ketorolac administration by days and dose (mg/kg) were identified from hospital records. Generalized mixed effects model for binary outcomes evaluated AKI based on laboratory variables and ketorolac administration. Generalized mixed Poisson effects model analyzed the association of AKI with hospital length of stay. Results Thirty three (17 %) of 197 admissions for vaso-occlusive pain crisis were associated with AKI. Fifty two percent of the cases presented to the Emergency Room (ER) with AKI. Every one unit drop 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 hospitalizations than patients without AKI. Conclusion AKI 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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“…The exclusion criteria were age less than 18 years or chief complaint unrelated to VOEs in patients with SCD. The patient sample size was estimated by data abstraction from a prior study27 using the following assumptions: μ (0) = 293 “known” mean value for SCD population; μ (1) = 236 “expected” mean” value from sample; σ (standard deviation) = 154 for the population; 2-sided test; α = .05; and β = .8. A sample of 58 patients per group was required to estimate a difference in time to initial administration of analgesic of 30 minutes and in LOS from triage to disposition in the UC center.…”

Section: Methodsmentioning

confidence: 99%

Evidence-Based Practice Standard Care for Acute Pain Management in Adults With Sickle Cell Disease in an Urgent Care Center

Kim

Brathwaite

Kim³

2017

Quality Management in Health Care

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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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Use of a clinical pathway to improve the acute management of vaso‐occlusive crisis pain in pediatric sickle cell disease

Abstract: The use of a clinical pathway for sickle cell VOC in the PED can improve important aspects of pain management and merits further investigation and implementation.

Cited by 31 publications

References 30 publications

A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department

A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department

Acute kidney injury during a pediatric sickle cell vaso-occlusive pain crisis

Evidence-Based Practice Standard Care for Acute Pain Management in Adults With Sickle Cell Disease in an Urgent Care Center

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