Abstract Topic: 26. Sickle cell disease
Background: Pain crises represent the primary reason for hospital care-seeking in individuals with sickle cell disease (SCD). The NICE guideline CG143 emphasises that patients should receive analgesia within 30 minutes of arrival to the emergency department, have hourly observations in the first 6 hours and pain score assessment every 30 minutes until satisfactory control. Patient should also be treated as experts in the pain management of their SCD.
Aims: To assess the annual performance of acute sickle cell pain crisis management at Cambridge University Hospital (CUH) and assess methods of secondary prevention of admission for pain crisis through patient pain education and compare results to the preceding 12-month period.
Methods: Patient admission records during the year of 2022 were reviewed for a population of 85 SCD patients registered at Cambridge University Hospital (CUH). For these encounters, patient assessment at presentation, primary analgesia and ongoing management were audited against CG143 standards. Over the period in question an EPIC based sickle cell registry was introduced in June 2021. This has allowed for 100% coverage of all known patients with preformulated pain plans. Educations sessions were provided to patients and A&E staff.
Results: In a population of 85 patients living with SCD, there were 32 admissions in 27 patients during 2022, of which 5 patients had multiple admissions (2021:22 admissions in 17 patients). Auditing CUH performance against the NICE CG143 guidelines, it was found that initial pain relief was provided within 30 minutes of presentation in 5 out of 29 relevant admissions (17%). In comparison, pain relief was provided within 30 minutes in 15 out of 21 (71%) relevant admissions in 2021 at CUH. The median time to analgesia was 60 minutes in 2022 with an interquartile range (IQR) of 51.5 minutes (2021: 31.9 minutes, IQR 20 minutes).
In 2022, the average number of vital sign measurements taken during the first 6 hours of presentation was 3.5 compared to recommended hourly observations recommended by NICE CG143. Figure 1 demonstrates timings of first sets of observations taken. Pain score was documented every 30 minutes until satisfactory pain control in 3 out of 32 admissions (2021: 7 out of 21 relevant admissions).
16 patients were admitted for the first time in this period as new patients to the hospital.
Alike in 2021, none of the patients had documented discussion of pain control education, any psychological support they may need nor were encouraged to use their own coping mechanisms for dealing with acute pain in their hospital notes.
Summary/Conclusion: Our audit has demonstrated a substantial year to year variation in providing timely analgesia to patients attending hospital for acute sickle cell pain crises. NICE CG143 guidelines recommends analgesia within 30 minutes of arrival, however American Haematology Society gives a recommendation of within 1 hour. Given the many factors affecting analgesia administration, including waiting time and staffing levels in the emergency department, current NICE recommendation is hard to meet, and the ASH guidance may be more realistic.
There continues to be a significant gap in the management of acute sickle cell pain crises at CUH with the absence of patient pain education. This may have contributed to the number of admissions of SCD patients to CUH.
Keywords: Sickle cell anemia, Sickle cell patient, Sickle cell disease, Sickle cell