Emergency Department Less Likely to Provide Recommended Care for VOEs, Study Finds

Children with sickle cell disease (SCD) who arrive at an emergency department with vaso-occlusive episodes (VOEs) are more likely to have a longer delay before treatment, receive less narcotics than recommended, and to be admitted to the hospital, compared with SCD patients who present to a specialty day hospital, a study found.

The study, “Management of vaso‐occlusive episodes in the day hospital decreases admissions in children with sickle cell disease,” was published in the British Journal of Haematology.

VOEs are the most common cause of emergency room visits for people with SCD. Current guidelines suggest that best treatment practice for VOEs is the rapid administration of opioids like morphine and hydromorphone, but such guidelines are helpful only if adhered to by patients.

In the new study, researchers compared adherence to these guidelines at the Pediatric Ambulatory Chemotherapy and Transfusion Unit (PACT) or the emergency department (ED) for their hospital in Cincinnati, Ohio. Typically, patients are encouraged to try to control VOEs using oral medication at home; if this is unsuccessful, it is suggested that patients go to the PACT if it is open (during the day Monday-Friday), where there are nurse practitioners familiar with SCD, or to the ED if it is not open.

The researchers collected data on 140 children (average age 10.9 years, 50% female) who made 370 visits to these two locations from February 2014 to May 2015, shortly after the hospital implemented the aforementioned guidelines for how to handle VOEs.

Specifically, 125 patients made 286 visits to the ED, and 46 patients made 84 visits to the PACT.

Generally, patients at the two locations were similar, though there were a few notable differences. For example, significantly more visitors to the PACT were on simple transfusion therapy (9.5% vs. 0.7%) and had attempted to manage their VOE at home with oral oxycodone and ibuprofen (66% vs. 41%). Additionally, patients who came to the ED had significantly higher pain scores (median 7 vs. 6 on a scale of 0–10).

Patients who came to the ED had significantly longer delays before the first analgesic was administered than those at the PACT (median 70 minutes vs. 32 minutes).

Patients at the ED also were significantly less likely than those at the PACT to get the recommended dosage of morphine (45% vs. 84%) or hydromorphone (43% vs. 100%). Interestingly, there wasn’t a difference in usage or dosage of non-steroidal anti-inflammatory drugs (which include over-the-counter pain meds like ibuprofen). This, the researchers wrote, “probably reflects a combination of under dosage of children in general and providers’ discomfort with utilizing higher dosages of opioid medications.”

Additionally, patients at the ED were about 3.8 times more likely to be admitted to the hospital than those at the PACT, even after adjusting for baseline differences between the two groups. Statistical models demonstrated that this discrepancy was directly associated with the administration of non-recommended dosages and delays in care.

This finding isn’t entirely surprising, the researchers wrote, because healthcare providers at the ED are less likely to be familiar with a particular patient’s case, which can make proper care difficult. That’s why it’s so important that the available guidelines be followed, and promptly, even when the available caregivers aren’t necessarily experts.

The researchers wrote that their institution is already taking steps to address this gap: “In order to improve the time to and appropriateness of the first analgesic, our ED has since implemented the use of intranasal fentanyl [another opioid medication] while awaiting IV access. Another potential solution would be to expand the hours and bed availability of the day hospital so that more patients could be evaluated and treated there.”

“A prospective study evaluating the management of pain in the day hospital versus ED is necessary to assess if standardized guidelines administered similarly can achieve comparable patient outcomes,” the authors concluded.