Are you giving poor care to sickle cell patients?
Are you giving poor care to sickle cell patients?
Complications can occur
A 33-year-old man with sickle cell disease complains of severe pain in his right arm and reports that attempts to treat the pain at home were unsuccessful. Since the man appears calm and vital signs are normal, the triage nurse gives the patient a low priority. But after waiting for more than an hour, the patient can’t tolerate the pain any longer — and reports to the triage area with loud, belligerent demands for service.
This is an all-too-common scenario in EDs, says JoAnn Beasley, RN, an ED nurse and sickle cell clinical manager at Grady Hospital in Atlanta, which treated more than 4,600 sickle cell patients in 2004.
The problem is that the patient’s reports of pain were not believed, Beasley says. "He had obviously attempted to control his pain prior to presenting to the ED," she says. "We now have a hostile patient in severe pain who probably will need additional medication because of the added stress of having to deal with unempathetic health care providers."
Sickle cell patients treated for pain in an urban ED had significantly lower general satisfaction scores when compared to nonsickle cell patients who presented with acute pain, a recent study found.1 "Sickle cell pain episodes are not considered an emergency in most EDs, with priority given to the cardiac, respiratory, and trauma patients," says Beasley.
But patients in severe pain have the need for emergent relief or they would not have presented to the ED in the first place, she insists. "Many of them have already self-medicated at home until they cannot bear the pain any longer, and then present to the ED," she says.
A struggle still continues between ED nurses and patients because of the nonacceptance of the patient’s report of pain, says Beasley. "Patients are dissatisfied because they are not believed, and medications are either being withheld or they are undermedicated for pain," she says.
To significantly improve care, do the following:
•Give pain medications on a fixed schedule.
"When prn dosing occurs, medication is given as needed or requested, and can result in delays and negative interactions with patients," Beasley explains. She gives the example of a patient given 10 mg intravenous (IV) dose of morphine more than four hours ago, but experiences only minimal relief. "The patient’s medication should have been ordered on a fixed schedule, especially with the report of minimal relief on the initial dosage," says Beasley. "Now after four hours, they will have to start the process all over again of getting a handle on the pain."
Prompt control of pain with adequate medications ordered on a schedule consistent with drug duration, given on a fixed dosing schedule, will better control pain by maintaining adequate blood levels, says Beasley.
•Initiate treatment rapidly.
Sickle cell crises can lead to complications including stroke, organ damage, blindness, and potentially death, so rapid treatment must be given, says Marianne Hatfield, RN, system director of emergency services at Children’s Healthcare of Atlanta. "Our first goal is to place patients in a treatment room as soon as possible — preferably immediately," she says.
If this isn’t possible, the triage nurse applies anesthetic cream and gives an oral dose of acetaminophen with codeine or hydrocodone-acetaminophen, says Hatfield. Once the patient is in a treatment room, the nurse can give IV ketorolac tromethamine prior to physician assessment.
"This is the one protocol in which the nurse can give an IV pain medication prior to being seen by a physician," she notes. "The physicians then usually will add a stronger medication such as morphine when they examine the patients." (See ED’s protocol.)
Blood is drawn for specific labs immediately upon placement in a treatment room, says Hatfield. "Unfortunately, sickle cell patients usually have had to endure quite a few blood draws, and they become the expert on which vein will be easiest to access, so we ask them if they have a preference," she says.
Complications may occur suddenly and can rapidly become severe, warns Hatfield. "Children with any type of sickle cell disease are susceptible to overwhelming sepsis," she says.
•Give antibiotics rapidly if patients present with fever.
Sickle cells can damage the spleen, which may make the patient more vulnerable to infections, says Hatfield. "Rapid administration of an antibiotic is indicated for sickle cell patients with fever," she says. "Our current goal is to administer antibiotics within 60 minutes of arrival to the ED."
For sickle cell patients with fever, the ED nurse does the following:
- establishes IV access;
- draws the following labs for stat resulting: Complete blood count with differential, reticulocyte count, and peripheral or central venous line blood cultures;
- administers IV ceftriaxone (75mg/kg) unless patient has a known allergy to ceftriaxone or penicillin;
- notifies the physician to obtain an IV fluid order.
Protocols are not initiated if a patient is found to be unstable with signs of respiratory distress, decreased systolic blood pressure, prolonged capillary refill, or compromised neurological status, says Hatfield. "These patients are immediately assessed by a physician, and care is directed at that time," she says.
Reference
- Philpott S, Mason J, Aisiku IP. Patient satisfaction in the emergency department management of acute sickle cell pain. Acad Emerg Med 2005; 12:158.
Sources/Resource
For more information on care of sickle cell patients in the ED, contact:
- JoAnn Beasley, RN, Clinical Manager, Georgia Sickle Cell Center, Grady Health System, 80 Jesse Hill Jr. Drive, Atlanta, GA 30303. Telephone: (404) 616-5990. Fax: (404) 616-0744. E-mail: [email protected].
- Marianne Hatfield, RN, System Director of Emergency Services, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Road N.E., Atlanta, GA 30342. Telephone: (404) 785-4968. E-mail: [email protected].
Protocols developed by the Georgia Sickle Cell Center can be accessed at no charge at www.scinfo.org. Click on "Health Care Providers Online Resources and Guidelines" and then "Sickle Cell Disease in Children and Adolescents: Diagnosis, Guidelines for Comprehensive Care, and Care Paths and Protocols for Management of Acute and Chronic Complications."
A 33-year-old man with sickle cell disease complains of severe pain in his right arm and reports that attempts to treat the pain at home were unsuccessful. Since the man appears calm and vital signs are normal, the triage nurse gives the patient a low priority. But after waiting for more than an hour, the patient cant tolerate the pain any longer and reports to the triage area with loud, belligerent demands for service.Subscribe Now for Access
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