Relief for pain crises often delayed by incorrect ER triage scoring
Ensuring patients receive correct score can improve care, experience: Study
People with sickle cell disease (SCD) seeking emergency care for vaso-occlusive crises (VOCs) are often not triaged appropriately, leading to unnecessarily long waits for pain relief.
A recent study finds that assigning the correct Emergency Severity Index score, a tool used in emergency departments to prioritize care based on a person’s condition, can make a major difference in how quickly patients receive treatment.
The study, “Use of Emergency Severity Index 2 Reduces Time to First Analgesia in Sickle Cell Disease Vaso-occlusive Crisis,” was published in Blood Advances.
“Pain is a significant burden in the day-to-day lives of those living with sickle cell disease, with VOC being the number one reason these patients present to the emergency department,” Abdulaziz Abu Haimed, MD, the study’s lead author and an internal medicine resident at the University of Maryland Medical Center at the time of the study, said in a press release. “When these patients arrive, they really need help, and as soon as possible. Our study shows that assigning them an appropriate emergency severity index (ESI) score substantially impacts the length of time it takes for them to receive their first dose of pain medication.”
Understanding sickle cell disease and VOCs
Sickle cell disease is a genetic disorder that predominantly affects people who are Black or of African descent. It is characterized by the presence of abnormally shaped red blood cells prone to getting stuck inside blood vessels, restricting or blocking blood flow, which can lead to VOCs.
Because VOCs can be excruciating, one of the top priorities when patients seek care in an emergency department is to quickly provide pain-relieving medication, such as opioids.
“Many patients describe VOC as the worst pain of their lives,” said Jennie Law, MD, a study co-author, hematologist-oncologist, and associate professor of medicine at the University of Maryland School of Medicine. “They sometimes compare it to the feeling you’d get from taking a tourniquet to your limb and tightening it.”
In emergency departments, clinicians use a triage process to determine who should be treated first. For example, people with life-threatening emergencies are usually prioritized over those with non-fatal complaints. A tool called the Emergency Severity Index, which ranks patients from a score of 1 (most urgent) to 5 (least urgent), is commonly used to help with triaging.
Guidelines from groups such as the National Heart, Lung, and Blood Institute and the American Society of Hematology generally suggest that a VOC in a sickle cell patient be assigned an ESI score of 2, with patients receiving pain relief medications within an hour of arriving at the emergency room.
Study reviews ER management and triage scores
Scientists at the University of Maryland reviewed data from 66 emergency department visits involving 41 sickle cell patients who came in for VOCs but had no other health emergencies. Most rated their pain as 9 or 10 (out of 10) when they arrived.
The researchers found about a third (34.8%) of visits were given an ESI score of 2 as recommended. For these patients, the median time from arriving at the emergency room to receiving pain medication was 65 minutes.
The remaining visits were given an ESI score of 3. Four patients given that score left the emergency room without receiving pain medications, and for the remaining patients, the median wait time to get pain relief was nearly three hours (178 minutes).
“Our study demonstrates that ESI assignment is a major determinant of [time from triage to administration of first analgesia], highlighting its important role in adherence to evidence-based guidelines for rapid administration of analgesia in the management of [sickle cell disease] VOC,” the researchers wrote.
The scientists noted that this analysis was limited to patients at a single urban center, which they described as being “overcrowded.” They also noted a need to validate the findings using data from other centers and for more research into how faster pain relief affects patients’ experiences in the ER. Still, they said the available data suggest appropriate ESI assignment may help prevent sickle cell patients from needlessly enduring pain.
“A patient with sickle cell disease assigned an ESI 2 compared to 3 is about six times more likely to receive pain medication quicker,” Abu Haimed said. “Ensuring we assign patients the recommended ESI is one small intervention that can significantly improve the quality of care and overall experience in the emergency department.”
Of note, one of the researchers has financial links to pharmaceutical companies.
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