Patients with sickle cell disease (SCD) who experience acute vaso-occlusive episodes may be more likely to be admitted to a hospital if they are treated in an emergency department (ED) compared with patients treated in day hospitals, according to research published in the British Journal of Hematology.
Guidelines for management of vaso-occlusive episodes in the ED recommend rapid administration of morphin or hydromprphin within 30 minutes of presentation. However, studies comparing management of vaso-occlusive episodes in EDs with treatment given in pediatric hematology- and oncology-specific day hospitals are scarce.
Researchers compared the hospital admission rates for patients with SCD treated for vaso-occlusive episodes in an ED (125 patients; 286 visits) and a day hospital (46 patients; 84 visits) in order to evaluate factors influencing admission rate.
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Mean patient age was 11 years. Time to first analgesic was significantly different between the patient groups, with a median of 70 minutes in the ED compared with 32 minutes in the day hospital (P <.0001). Furthermore, adherence to guidelines regarding initial choice and dosage of intravenous opioid differed between the groups; morphine dosage ascribed to guideline in 45% of ED visits compared with 84% of day hospital visits (P =.0003), while hydromorphone dosage ascribed to guideline in 43% of ED visits compared with 100% of day hospital visits (P =.002).
Hospital admission rates were 57% from the ED and 29% from the day hospital (P =.0001). After adjusting for baseline factors, the odds of a patient presenting to the ED being admitted were 3.8 times higher compared with a patient presenting to a day hospital (odds ratio [OR], 3.8; 95% CI, 1.9-7.8; P =.001].
Modifiable factors affecting admission included intravenous opioid dosage that did not adhere to guideline (OR, 2.1; P =.02) and care obtained in the ED (OR, 3.9; P =.001). Nonmodifiable factors affecting admission included initial pain score (OR, 1.2; P =.004) and fever at presentation (OR, 4.5; P =.002).
The authors concluded that “ED physicians were more likely to use less-than-recommended opioid dosages compared with providers in a sickle cell-specific day hospital.” As a result, day hospitals may be feasible alternatives for patients with SCD seeking acute pain management. In addition, rapid administration and appropriate dosing of intravenous opioids may decrease the discrepancy in admission rates reported in this study.
Reference
1. Karkoska K, Appiah-Kubi A, Rocker J, Stoffels G, Aygun B. Management of vaso-occlusive episodes in the day hospital decreases admission in children with sickle cell disease [published online May 31, 2019]. Br J Haematol. doi:10.1111/bjh.16002
