The Adult Sickle Cell Patient in the Emergency Room: Goals of Care

1. The Adult Sickle Cell Patient in the Emergency Room: Goals of Care Ron Brathwaite MD September 5, 2019 11th Annual Sickle Cell Disease Educational Seminar

2. The Adult Sickle Patient in the ED • I have no financial disclosures or conflicts of interest with the presented material in this presentation

3. Objectives • There is room for improvement in ED care for the Adult SC Patient • Improvement will occur when there is Departmental will to do better • The improvement process will include Patients, Nurses, Doctors, auxiliary staff • Must measure pre and post intervention

4. Case #1 • 26 yo female with known sickle cell disease presents to the ED complaining of severe back pain. She has tried dilaudid 4 mg by mouth every 3 hours overnight with little relief of her pain. She states that the pain is uncontrolled and she checks into the ED at 1000 am on Monday morning. • She is triaged and vitals signs are temp: 98.6, pulse: 101, rr: 18, bp: 140/75. Patient appears uncomfortable. She is informed by the triage nurse that she will need to go out to the waiting room until a bed becomes available. The patient asks the nurse if she could receive some pain medication now and nurse says “we can not give you pain medication without monitoring you” • Patient is ushered out to waiting room.

5. The Adult Sickle Cell Patient in ED 1. Does your hospital have an agreed about triage level for SC patients presenting with pain? 2. Does the triage nurse agree with equating SC patients with other acute pain patients such as chest pain , fractures or trauma? 3. Does it matter if it is a new patient to your system or a returning patient in regard to urgency to address pain ?

6. The Adult Sickle Cell Patient in ED • The patient arrived at 1000 and it is now 1200. The patient has been observed rocking back and forth in her chair in the waiting room. The ED doctor has been approached about putting this patient in a bed but currently there are no beds available. The triage nurse offers the patient 650 mg of Tylenol and tells her it will be a “little while longer”. Patient last took dilaudid at 0900.

7. The Adult Sickle Cell Patient in ED • How can the space between triage assessment and patient being placed in a bed be best used? • Should all SC patients be fast tracked to next bed available, regardless of what else is going on in ED? • The space between triage and patient in a bed is vital real estate how is it currently being used?

8. The Adult Sickle Cell Patient in ED • The patient is finally placed in a bed at 1 pm. Her vitals are again taken and are unchanged. She is kindly informed that the Doctor will be with her shortly. The patient asks the nurse when she will get any pain medication, she is told “ you have to wait for the Doctor to see you first” • At 1330 (3 .5 hours after arriving at the ED ) Dr. Brathwaite arrives to the bedside to take a history. When he arrives the patient is rocking back and forth with her headphones on with her eyes closed. The nurse had informed the Doctor that the patient looked comfortable and she “does not know why these patients keep coming here.” • The Doctor takes a quick history and steps out of the room and subsequently orders oxygen via NC , IV placement, bolus 50. cc NS and dilaudid 0.5 mg IV x 1 and chest xray

9. The Adult Sickle Cell Patient in ED • The nurse receives the order for IV and gets supplies together. It is now almost 2 pm (4 hours after patient presented to triage). It is well known that this patient is a “difficult stick” so after one try and the patient appearing agitated, the nurse consults with more senior nursing staff who go in search of the vein finder. Patient finally achieves access after multiple sticks at 230pm. • The nurse goes to obtain dilaudid from the pyxis but currently no dilaudid is available and she has to call to the pharmacy to obtain the ordered dose. • Patient receives first dose of dilaudid at 3 pm (5 hours after she presented to presented to triage) . Her pain scale prior to dose is 10/10. The ED is very busy and nurse returns in 30 minutes to assess patient . At the re-assessment patient pain is still 10/10. Doctor is notified.

10. The Adult Sickle Cell Patient in ED • How does the ED prepare for the SC Patient? • How does one determine starting dose of pain medication? • How does reassessment move along the care of the SC Patient? • Who is the time -keeper in regards to care of the SC Patient in ED? • What are the metrics of great SC Patient care? Is your ED recording them? • What comes next?

11. The Adult Sickle Cell Patient in ED • The Doctor orders Diladuid 1 mg IV x 1 in response to patient pain 10/10. Patient now is irate and crying. She says that no one is listening to her and she refuses taking vital signs. It is now 1600 and she arrived at 1000. 6 hours ago. She has received a total of Dilaudid 1.5 mg IV x 1. • The Doctor is called into the room because Nurse states that patient is being aggressive • Doctor informs patient that “if she doesn’t like what we are doing she is free to leave”. • Patient asks for nurse to take peripheral IV out. She immediately leaves the ED crying.

12. The Adult Sickle Cell Patient in ED • At this point no one is happy • Doctor is not happy because labs came back showing hgb 5.5 and wbc 15 and patient should be admitted, but the patient just left AMA. • The nurse is not happy because “these patients come in here all the time looking for dilaudid and when they do not get what they want they leave” • Most importantly the Patient because she has not had any improvement and risks complications morbidity and mortality from untreated acute crisis.

13. The Adult Sickle Cell Patient in ED • Triage • Treatment dead zone between triage and bed • Rapid assessment • Rapid re-assessment • Appropriate pain management • SC complications lurking • Admit or Discharge Decision • Follow up