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3874 Association between Acute Pain Scores in Children with Sickle Cell Disease and Emergency Department Disposition and Return Visit Rates

Program: Oral and Poster Abstracts
Session: 114. Sickle cell Disease, Sickle Cell Trait and Other Hemoglobinopathies, Excluding Thalassemias: Clinical and Epidemiological: Poster III
Hematology Disease Topics & Pathways:
Research, Sickle Cell Disease, Clinical Research, health outcomes research, Hemoglobinopathies, pediatric, Diseases, neutropenia, registries, white blood cell disorders, young adult , Study Population, Human
Monday, December 11, 2023, 6:00 PM-8:00 PM

Keli D. Coleman, MD1*, Kenneth McKinley, MD2*, Angela M. Ellison, MD, MSc3*, Elizabeth R. Alpern, MD, MSCE4*, Selena Hariharan, MD5*, Irina Topoz, MD6*, Morgan Wurtz, DO7*, Blake Nielsen, MStat8*, Lawrence J. Cook, PhD9*, Claudia R. Morris, MD10, Amanda M. Brandow, DO, MS11, Andrew D. Campbell, MD12, Robert I. Liem, MD13, Rachelle Nuss, MD14*, Charles T. Quinn, MD, MS15, Alexis A. Thompson, MD, MPH16, Anthony Villella, MD7*, Allison A. King, MD, PhD, MPH17, Ana Baumann, PhD18*, Warren Frankenberger, PhD19* and David C. Brousseau, MD, MS20

1Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin and the Children's Research Institute of Children's Wisconsin, Milwaukee, WI
2Children's National Medical Center, Washington, DC
3Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
4Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
5University of Cincinnati College of Medicine, Cincinnati Children's Hospital, Cincinnati, OH
6Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO
7Nationwide Children's Hospital, Columbus, OH
8University of Utah, Salt Lake City, UT
9Pediatric Critical Care, University of Utah, Salt Lake City, UT
10Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA
11Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation, Medical College of Wisconsin and Children’s Research Institute of Children’s Wisconsin, Milwaukee, WI
12Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC
13Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
14Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Campus, Aurora, CO
15Division of Hematology, Cincinnati Children's Hospital Med. Ctr., Cincinnati, OH
16Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA
17School of Medicine, Washington University, Saint Louis, MO
18Washington University School of Medicine, St. Louis, MO
19Children's Hospital of Philadelphia, Philadelphia, PA
20Nemours Children's Health and Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE


Reducing pain through prompt administration of pain medication in the emergency department (ED) is a primary driver of national guidelines for sickle cell disease (SCD), yet there are few data on how pain scores and changes in pain scores are associated with both the disposition at the initial visit and the likelihood of a return visit. In this study, we analyzed acute pain scores from ED visits for children with uncomplicated SCD pain crisis to determine the relationships between pain scores and disposition (admission or discharge) or occurrence of a return ED visit.


For children with uncomplicated SCD pain crises, we aimed to determine (1) the association between initial pain score, last pain score, change in pain scores and the disposition of index ED visits, and (2) the association between these pain score values, number of parenteral opioid doses in the ED, whether an opioid prescription was provided at discharge, and an ED return visit within 14 days.


This is a multicenter retrospective cohort study of acute pain scores of ED visits by children for uncomplicated SCD pain crises. It was conducted using electronic health care data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry across 7 sites (Lurie Children’s, Children’s Hospital of Philadelphia, Cincinnati Children’s Hospital, Children’s National Medical Center, Children’s Colorado, Children’s Wisconsin, and Nationwide Children’s). Index ED visits were defined as uncomplicated pain crises with no preceding ED visits within 14 days between 01/2017 – 11/2021. We collected the following ED pain scores: initial, last, and change in scores (initial minus last) as measured by a numeric rating scale (0-10). For analyses related to disposition, we modeled the relationship between the three pain scores and hospital disposition adjusting for age, sex and uncomplicated pain crisis visit admission rate. For analyses related to return visits, we utilized the same predictor variables and added both the number of parenteral opioid doses administered in the ED and whether or not a prescription for an opioid was given at discharge. For all analyses, adjustment for site was made using generalized estimating equations with an exchangeable correlation structure to account for clustering within site. Modified Poisson regression was used to identify associations. SAS software version 9.4 was used for all statistical analyses.


A total of 4,985 index visits for uncomplicated SCD pain crisis were included; 52% resulted in hospitalization. Overall, 39% of the children were <12 years old, 54% were female, and 96% were Black. Eligible index ED visits per site varied from 157 to 1855. The overall ED median (IQR) initial pain score was 8.0 (6.0-10). The median last pain score was 5.0 (2.0-8.0); median change in ED pain score was 2.0 (0.0-5.0). In univariate analyses, higher initial and last pain scores and a smaller change in pain scores were all associated with higher hospitalization rates. Adjusted rate ratios (95% CI) from multivariable models showed last pain score was the best predictor of admission 1.16 (1.12, 1.19), with change in pain score no longer significant 0.98 (0.96, 1.00). Examining percent of children hospitalized by last pain score shows over 80% of children with a last pain score of 7 or higher were hospitalized, compared to less than 40% if 4 or lower (Figure 1). 29% of the 2,377 visits that were originally discharged to home had a return visit within 14 days. None of the included pain scores from the initial visit (initial, last, or change) were associated with having a return visit within 14 days. However, both an increased number of ED opioid doses and failure to receive a prescription for an opioid at discharge were associated with increased return visits. Figure 2 shows the ED opioid doses and prescription for opioid combination and their respective return visit rates, with a high of 36% for ≥ 3 doses of ED opioid doses and no prescription and a low of 22% if 1 opioid given and a prescription at discharge.


We found that for a child with SCD presenting to the ED with an uncomplicated pain crisis, the last ED pain score was a better predictor of hospitalization than initial or change in pain score. None of those pain scores predicted a return visit after discharge; however, fewer opioid doses in the ED and receipt of an opioid prescription at discharge were associated with fewer return visits.

Disclosures: Morris: Trility: Consultancy, Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Other: ad hoc consultant; Food as Medicine Therapeutics: Current Employment, Current equity holder in private company, Other: Executive Director of new Start-up company; CSL Behring: Consultancy, Other: ad hoc consultant; UCSF-Benioff Children's Hospital Oakland: Consultancy, Patents & Royalties: Inventor of licensed patents generating royalties. Campbell: Vertex: Consultancy; Bluebird Bio: Consultancy; Global Blood Therapeutics: Consultancy; Novartis: Consultancy; Agios: Consultancy; Forma: Consultancy. Liem: NIH/NHLBI: Research Funding; NIH/NCATS: Research Funding; Vertex: Research Funding; Bluebird Bio: Research Funding; Editas: Research Funding; Global Blood Therapeutics: Research Funding. Quinn: Emmaus Medical: Research Funding. Thompson: Editas: Consultancy, Research Funding; CRISPR/Vertex: Consultancy, Research Funding; global blood therapeutics: Divested equity in a private or publicly-traded company in the past 24 months; Beam: Consultancy, Research Funding; bluebird bio, Inc.:: Consultancy, Research Funding; Novartis: Research Funding. Villella: Vertex CRISPR Therapeutics: Consultancy. Brousseau: CSL Behring: Consultancy, Honoraria.

*signifies non-member of ASH