We chose to compare time to initial analgesia using SCD and RC based on our anecdotal experience with patient presentation at triage, as well as previous data demonstrating lengthy delays to administration of initial analgesic for patients with SCD.6
We believed comparing the management of adults with sickle cell pain crises to patients with a similar pain presentation would provide further insight into the management of sickle cell pain crisis. We chose renal colic because of its similarities in presentation to SCD with regards to severity and abrupt onset of presentation of pain episode. While many patients with SCD suffer from chronic pain, many also still experience severe pain crises that are often sudden in onset and require aggressive opioid management.12
Our data from this project found patients who presented to the ED with an acute pain crisis associated with SCD experienced significantly longer delays to the administration of the initial analgesic compared to patients with RC, despite higher arrival pain scores and higher triage acuity levels. These differences were independently associated with disease state, arrival shift, lower priority triage levels, ability to obtain intravenous access, and gender. Previous studies have also found patients with RC experience more rapid treatment when compared with all ED patients who received morphine sulfate for treatment of acute pain.5
Delays associated with arrival shift may reflect crowding, however, regardless of arrival time, we found delays were still consistently longer for patients with SCD. Patients arriving during the night shift experienced the shortest time to receiving an initial analgesic; this is a variable that cannot be controlled. Our data are supported by previous work examining the affect of arrival shift on delays to analgesic administration among patients with RC. Patients arriving on the evening shift experienced the longest delays, with the shortest delays for patients arriving on the night shift.4, 5
Patients with SCD experienced significantly longer delays to administration of the initial analgesic when compared to patients with RC. More concerning is the discovery of disparate wait times incongruous with the triage levels assigned to these patients. Patients with SCD reported a higher pain score and were appropriately given a higher priority triage level yet experienced significantly longer times to analgesic than RC patients with lower pain scores and lower priority triage levels. While statistically significant, the clinical significance of this small difference in presenting pain scores between the two groups is unknown. However, pain scores in both groups were >7, which is generally recognized as representing severe pain. The pathophysiology of SCD would suggest that rapid evaluation and management of patients is critical. The pathophysiology of the two disease states is clearly different. SCD is caused by a genetic mutation resulting in replacement of glutamic acid by valine on the beta chain of hemoglobin leading to red blood cell sickling during a deoxygenated state.15
Patients with SCD have resultant potential complications including sepsis, stroke, acute chest syndrome, chronic anemia, avascular necrosis, pulmonary embolism, pulmonary hypertension, renal failure, cirrhosis, and acute and chronic pain.15, 16
These complications are serious and contribute to the early age of death in males and females, 48 and 42 years, respectively.10
Recent data comparing ED utilization of SCD patients suggest patients with three or more ED visits per year have more pain crises, higher pain scores, more pain days, worse quality of life (physical function), lower hematocrits, higher white blood cell counts, and needed more transfusions in the last three months.17
Other data support the concept that ED patients with frequent ED visits and hospitalizations are at high risk and should be rapidly evaluated. In a two-year cohort study of 71 patients, patients with a higher number of hospitalization days were at an increased risk of death. (Houston-Yu 2003). In a separate study, 50% of ED patients with acute pain crisis were re-admitted within one month, and 16% within one week. The mortality rate for those re-admitted within one week was 20% compared with an overall morality of 14% for the cohort. (Ballas, 2005). These data suggest that patients with SCD and many ED visits are at high risk; rapid evaluation and management is critical.
Renal colic is caused primarily by metabolic alterations causing hyperexcretion of minerals such as calcium and uric acid leading to calculi formation and passage through the genitourinary system resulting in acute pain episodes. Other than potential for sequelae from obstructive or infected calculi, patients with RC generally revert to their baseline normal state of health after an attack, although some may be associated with other chronic medical conditions such as gout, Crohn’s disease or hyperparathyroidism.15
Timely evaluation of the patient with renal colic is primarily to exclude other life threats, such as a ruptured abdominal aortic aneurysm. Once the diagnosis of renal colic is established, recurrent pain from additional episodes of renal colic is rarely dangerous. While many similarities in presentation between SCD and RC exist, there are many important differences in pathophysiology and co-morbidities that should encourage more rapid placement and evaluation for patients with SCD. Although patients with SCD often present complaining of pain typical of past crises, other potentially serious and life-threatening morbidities need to be rapidly ruled out by a physician. Ideally, rapid evaluation and management of patients with either SCD or RC should always be facilitated.
Assignment of a lower priority triage level (ESI 3, 4, or 5) also predicted delays to administration of the initial analgesic. Our data are similar to findings from several recent studies that found patients who received a low priority triage score experienced longer delays to administration of analgesics2, 3, 5
. In the context of crowding, assignment of a lower priority triage level has a great impact on delays to care for all patients. Patients triaged appropriately as Level 2 often still experience longer than desired waits in the context of crowding, however assigning a lower priority triage level will definitely lead to even longer delays to care. The ESI triage system is used the study site. ESI clearly defines patients with severe pain that cannot be managed at triage as meeting ESI level 2 criteria.14
Patients with either SCD or RC and pain scores >7/10 meet this definition.
For patients with SCD, the pain experience itself has been shown to be similar between genders.18
However, previous data and data from this study show differential time to analgesia for patients with SCD between genders, with females having even longer delays to administration of initial analgesia than males. To the best of our knowledge, there does not appear to be data regarding pain or treatment differentials between genders for patients with RC. The meaning of gender differences in this sample is unclear.
There are several other factors that we were unable to measure that may have also contributed to differences in the time to administration of the initial analgesic. Obvious racial differences between disease cohorts exist; patients with SCD in the United States are predominantly black; those with RC are predominantly white.19
Indeed, in our cohort of patients with sickle cell disease, there were only two Caucasian patients. Without variability in race, we were unable to measure the affect of race as a variable. Race does need to be considered as a possible root cause for the disparity. Recent data demonstrate that blacks are still prescribed opioids at lower rates than any other race/ethnicity group for almost every type of pain visit.20
Race as a contributing factor to disparities in the administration of analgesics in the ED setting has been well documented and predominantly continues to exist.1, 2, 20-24
One additional factor that may contribute to delays in analgesic administration for patients with SCD is frequent ED utilization by some patients. However, our data do not support this. There were no differences in overall time to administration of the initial analgesic for patients with SCD who had few visits (1-3) when compared with SCD patients with 4-9 visits or ≥13 visits during the study period. Fifteen percent of our sample did have ≥13 visits, which may lead to EM clinician frustration. A lack of access to an outpatient physician for the long-term management of SCD can contribute to increased utilization of the ED. Some patients with SCD may primarily use the ED as their source of health care and become deemed “well-known” to the ED staff, which may hinder rapid assessment, placement, and analgesic management. Previously reported data demonstrate ED visit patterns inconsistent with hospital staff assumptions about frequency of patient visits.6
In one study in 2004, 159 different patients at 3 study sites accounted for 612 patient visits for acute pain crisis from SCD. Seventy three percent of the visits were from patients who presented between 1-3 times during the 12-month study period. Less than 7% of total visits were by patients who presented greater than 15 times in one year. Additionally, patients with low ED utilization experienced similar delays to initial analgesic administration as patients who were high ED utilizers. The perception of frequent visits (which some patients do indeed have) may lead health care practitioners to categorize all
patients with SCD as “frequent users” and lead to practitioner frustration and resultant patient stereotyping. Compounding the problem, health care practitioners may then categorize these “frequent users” as “drug seeking.” Aisiku and colleagues have recently shown that ED “high utilizers” with SCD are sicker than SCD patients with low ED utilization (<3 ED visits/year).17
Finally, we also measured differences in the administration of NSAIDs between diagnostic cohorts. Despite current recommendations for administration of NSAIDs in both disease states, in SCD as an adjuvant analgesic and in RC as a primary analgesic, patients with RC received NSAIDs significantly more often than those with SCD.25, 26
Barring contraindications, NSAIDs are important agents that should be administered for optimal treatment of pain from both SCD and RC.
Several limitations apply to our findings. We conducted a medical record review and all the associated limitations apply. However, nursing documentation of medication administration time is very accurate. The data reported here are from a single site; however the larger project reported previously included two other sites and reported similar lengthy delays.6
While we were able to measure whether or not intravenous (IV) access was obtained at any point during the ED visit, we were not able to measure the time it took to obtain IV access. Attempts to obtain IV access can inadvertently lead to delays in administration of analgesics. Our data support this; SCD patients with IV access still experienced a 20-minute delay compared with RC patients. Patients with SCD often have sclerotic veins, are often dehydrated, and therefore may have problems with IV access. Patients with RC are less likely to have the same IV access issues. Attempts at obtaining IV access followed by delayed IM administration of analgesia may have occurred and contributed to the longer delay to analgesic administration in patients with SCD. However, a lack of IV access should not lead to delays in early management of acute pain crisis. Guidelines recommend initiating pain management with subcutaneous opioids when an IV route is not obtainable.25
The subcutaneous route is routinely used in cancer and palliative medicine and has been shown to be as efficacious as other routes when intravenous access is unobtainable. 27
We were also unable to measure whether or not patients took oral opioids prior to the ED visit. If clinicians perceived patients with SCD were more likely to take oral opioids prior to the ED visit when compared with RC patients, it is possible they may have elected to wait to see if the oral analgesics would have been sufficient, thus contributing to a longer time to initial analgesic. However, patients with SCD presented with higher pain scores, which could also lead EM clinicians to the assumption that oral analgesics taken at home were not effective. Finally, it is routine practice in emergency departments to administer strong opioids (complaint specific) when patients present with severe pain severe even if they have taken oral opioids prior to arrival.
We were also unable to measure the affect of sociodemographic status on the primary outcome. We could not measure the effect of race because there were no Caucasian patients with SCD. While comparison of insurance status might be considered a proxy measure of sociodemographic information, this data was not abstracted. Most importantly, differences in insurance status should not guide management. Since the 1986 enactment of the Emergency Medical Treatment and Labor Act (EMTALA), public access to emergency services has been regardless of an individual’s ability to pay.28
At the study site, which is a Medicare-participating hospital and is bound by EMTALA, providers are unaware of individual patients’ insurance status.
Finally, we did not measure method of arrival. Patients arriving by ambulance in some EDs are automatically placed in a treatment bay, which would usually result in more rapid time to receiving an initial analgesic. However, at the study site, the charge nurse evaluates all patients arriving by ambulance and then directs non-critical patients to the waiting room for further assessment. We have no reason to believe more patients with SCD were triaged to the waiting room than RC patients.
Future research should focus on several areas that may help both explain and improve upon delays to analgesic administration for patients with SCD. It is important to begin to understand the reasons why a minority of patients with SCD are high ED utilizers. Possible reasons could include a more severe disease process, uncontrolled acute and chronic pain that require improved outpatient management, the inability to find a physician with expertise in SCD management, and other psychosocial factors. To improve analgesic management for patients with SCD in the ED, it will be important to measure the impact of both patient specific and department analgesic protocols for SCD patients. These protocols should be physician/nurse developed, nurse-initiated, and incorporate more usage of subcutaneous administration of opioids to decrease time to administration of the initial analgesic. Several guidelines recommend parenteral administration of analgesia as the first line route for patients presenting to an ED in severe pain.11, 25, 29
Oral analgesics should be avoided due to their delayed onset of action and because most patients have already taken oral opioids prior to coming to the ED. Patients with both SCD and RC experienced delays to initial analgesia, and proactive innovations that reduce time to initial analgesia regardless of disease state are needed throughout emergency departments.