ED pain scores may predict future hospitalization for SCD children
Study finds opioid management also plays role in likelihood of return visit
Higher pain scores at the time of discharge from the emergency department (ED) may predict the likelihood of hospitalization in children with sickle cell disease (SCD) who seek emergency care for acute pain episodes, according to a study in the U.S.
The study also found that patients with severe pain upon both ED arrival and discharge, and who received multiple opioid doses for pain management but were not prescribed opioids upon discharge, were more likely to return to the ED within 14 days.
“Our work may be particularly impactful for the development and impact assessment of outpatient guidelines for acute SCD pain management following an ED visit for acute pain events,” study authors wrote.
The study, “Associations Between Pain Scores and Opioid Doses With Emergency Department Disposition and Return Visit Rates in Children With Sickle Cell Disease,” was published in Pediatric Blood & Cancer.
Team analyzed health records from nearly 5K ED visits for SCD-related pain
SCD is characterized by symptoms such as recurrent episodes of pain, known as vaso-occlusive crises, caused by blocked blood flow in small vessels. These acute painful events are the leading cause of ED visits, hospitalizations, and rehospitalizations among children with SCD.
Clinical guidelines for managing SCD-related pain recommend prompt opioid administration, earlier than 60 minutes of arrival at the ED, and frequent pain reassessment every 15 to 30 minutes, with further opioid doses administered until the acute pain is adequately controlled.
However, “the relationship of pain scores to the number of opioid doses received prior to discharge, prescription at discharge, and return visit rates is unknown and vital to understand to improve SCD pain care and decrease the high return visit rates,” the researchers wrote.
To learn more, a team of researchers retrospectively analyzed electronic health record data from 4,983 ED visits for SCD-related pain in children using the Pediatric Emergency Care Applied Research Network Registry. These visits, which took place at seven U.S. pediatric hospitals between 2017 and 2021, included only those without other serious or complex medical issues.
Among the visits, approximately 61% involved adolescents ages 12 to 18, and 54% of patients were female. Overall, more than half of the patients (52%) were admitted to the hospital following their ED visit.
‘Opioid prescription at discharge may help prevent return visits’
Pain scores were standardized to a uniform 0-to-10 scale, enabling direct comparison across sites and patient visits. These included the pain score recorded at ED arrival, the last pain score documented just before discharge, and change in pain score, calculated as the difference between the initial and last scores to reflect the degree of pain relief achieved during the visit.
The median initial pain score was 8, indicating severe initial pain, the median final score was 5, and the median decrease in pain score was 2 points.
Patients ages 12 to 18 and those reporting higher pain scores were more likely to be admitted to the hospital following an ED visit.
The last recorded pain score emerged as the strongest predictor of hospitalization, with admission rates rising in direct proportion to the severity of pain, the researchers noted.
Our results suggest an opioid prescription at discharge may help prevent return visits for acute SCD pain.
Fewer than 30% of children with a final pain score between 0 and 4 were admitted, compared to 50% to 60% of those with scores of 5 to 6. More than 80% of children were hospitalized when the last recorded pain score was 7 or higher.
“While higher pain scores would logically be associated with higher hospitalization rates, the reasons why some children with high pain scores are not hospitalized and some with low pain scores are hospitalized are unknown,” the researchers wrote. “The pain score–hospitalization relationship could be influenced by issues such as social or environmental factors (e.g., transportation issues, lack of resources), patient/parent preferences, and differences in pain thresholds.”
Among the 2,377 children discharged, 29% returned to the ED within 14 days.
The return visit rate was highest (36%) among those who received three or more opioid doses in the ED but were not prescribed opioids at discharge. In contrast, children who received only one opioid dose and were sent home with a prescription had a significantly lower return rate of 22%.
“Our results suggest an opioid prescription at discharge may help prevent return visits for acute SCD pain,” the researchers wrote.
Return visit rates were also higher in children with severe pain at both ED arrival and discharge, reaching 31% for children with initial scores of 7 to 10, and 33.5% for those with final scores of 7 to 10.
“These data assist in identifying high-risk groups and in the development of strategies and interventions to optimize pain treatment, champion clinical decision-making, and improve care, which could decrease ED return visits,” the researchers concluded.
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