This is ReachMD. Welcome to this special series, Changing the Conversation about Sickle Cell Disease, sponsored by Pfizer.
On this episode, What You Need to Know About Sickle Cell Disease Management, we will hear from Dr. Jason Wilson, Assistant Professor and Director of Clinical Research in the Division of Emergency Medicine at University of South Florida.
So, your sickle cell disease patient is most likely not a drug seeker. 75% of the patients with sickle cell disease who visit our emergency department only visit one time a year. This suggests that most patients who visit the ED are really not drug seekers but are actually in acute crisis or a field outpatient management or home management. One of the counterintuitive things is that the earlier the pain is managed, the less likely that patient is going to be admitted and the shorter the length of stay. So, trusting the patient and providing opioids early in the visit allows a decrease in admissions and decreased ED length of stay. Whether patients in a veno-occlusive crisis or is presenting with a long-term sequelae of opioid dependence related to veno-occlusive crisis may not really be that important in an era when analgesia is mainstay of therapy.
There really is no objective evidence for veno-occlusive crisis. Stratification tools have failed, reticulocyte counts don’t correlate. Patients may be in acute veno-occlusive crisis with completely normal vital signs, a normal reticulocyte count. We have to rely on the patient and those subjective symptoms of pain.
Sickle cell disease patients get sick. Management of veno-occlusive crisis at least provides us time to rule out other emergent disease states. Don’t forget that veno-occlusive crisis can commonly present with much more serious disease like acute chest pain or sepsis or pneumonia. Eventually these sickle cell disease patients who come to your emergency department are going to come in with one of those disease states.
Transition of care planning is critical for managing a population of patients with sickle cell disease. You must implement an evidence-based management and best practice pathway. You got to expect some pathway failure though the best ED care involves input from the community, hematology physicians who also treat outpatient disease. Integrate this with the outpatient and inpatient pathway. The ED pathway has to be prearranged with order sets and there needs to be clear expectation from providers and patients so there are not gaps in those expectations during an acute ED encounter. Admission should involve well-educated and well-trained staff who continue implementation of that order set. If there’s interruption of that order set things kind of start over and the likelihood of failure for that pathway likely increases. There should be minimal interruption of the best practice pathway and there should be safety nets in place when that practice pathway fails. Don’t forget that sickle cell disease is ultimately likely to be a terminal disease state for these patients. Whether they die of acute chest pain or sepsis or some other sequelae of the disease, we have to keep this in mind when we’re managing pain.
The ability for good medical management to extend life will likely lead to opioid dependence, that’s part of the disease state right now. So, when a patient comes in seeking opioids, remember they likely have real pain, they have real disease, they have a lifelong history of dealing with this disease and trying to medically manage the symptoms.
The proceeding program was sponsored by Pfizer. To revisit any part of this discussion and to access other episodes in this series, visit ReachMD.com/SickleCellConversations. Thank you for listening.