Acute Care in the Emergency Department Differs before and after Transition for Adolescents and Young Adults with Sickle Cell Disease

Background

Painful vaso-occlusive crises (VOC) are the most common cause of emergency department (ED) visits in patients with sickle cell disease (SCD) and are a major point of contact between patients and the health care system. Transition from pediatric to adult care has not been studied in the acute care setting. We examined whether management of VOC in adolescents and young adults differed between the pediatric and the adult ED.

Methods

A retrospective chart review was performed for all ED encounters in our hospital system for acute pain in patients with SCD, ages 13-23 years, between 2011-2013. Comprehensive medication administration data was collected for the ED visit as well as for the ensuing hospitalization, when applicable. Demographics and baseline medical data were collected. The equianalgesic dose, expressed as mg of intravenous (IV) morphine, and time to first analgesic administration were calculated. Equianalgesic dose and time to first analgesic were compared between the pediatric and adult ED using analysis of variance. In patients who were hospitalized, the total opioid dose received in the first 24 hours and the mean daily total opioid dosage during hospitalization were compared. Results were adjusted for correlation within multiple visits by individual patients, baseline hemoglobin, and presenting pain scores.

Results:

193 visits by 45 subjects, half of whom were male (44% M pediatric, 56% M adults), and most of whom had either HbSS or HbSβ⁰ (59% pediatric, 83% adults), were examined. Time to medication administration in the pediatric ED was 72 minutes vs 131 minutes in the adult ED (p<0.05, Figure 1A). Opioid medications were administered in 96% of all visits. The adjusted equianalgesic dose of the first opioid medication was 5.4 mg and 10.6 mg in the pediatric and the adult ED, respectively (p<0.0001, Figure 1B). The first opioid administered was parenteral hydromorphone in 4% of pediatric visits and 72% of adult visits. Preliminary analysis suggests that transition-age patients also received higher medication dosages during ensuing admissions to the adult hospital when compared with the pediatric hospital.

In a secondary analysis of 5 patients seen in both the pediatric and adult EDs during the study period, wait times were 56 and 158 minutes (p<0.05), and the equianalgesic doses of the first opioid administered were 4.7 mg and 7 mg, respectively (p<0.05).

Conclusions

These data suggest significant differences in acute pain management between pediatric and adult hospitals for transition-age patients with SCD. Possible reasons for observed differences include a larger patient volume in the adult ED, increasing disease severity with age, and the preference for use of higher potency hydromorphone among adult providers. Our data suggest that optimal transition management for adolescents with SCD must include strategies for transition in acute care management, focusing on limiting wait times and consistent dosing and titration of pain medications.