Establishing a Baseline: Impact of Pain Plans on Emergency Department Reliance and Length of Hospital Stay in Sickle Cell Disease Patients
Authors: Oberoi Anjali Rajkumari , Zhang Tina Y , Murphy Carolyn , Winokur Daniel , Khanna Shrinkhala 
Published: December 2024

Background: Sickle cell disease (SCD) commonly manifests with recurrent vaso-occlusive pain crises, often leading to chronic pain and frequent emergency department (ED) visits and hospitalizations. Chronic pain plans include tailored analgesic regimens for treating vaso-occlusive pain at home to prevent hospitalization. Acute pain plans outline regimens for patients presenting to an ED. This study aimed to evaluate the current relationship between the availability of an acute or chronic pain plan and ED reliance, time to administration of first pain medication, and the length of hospital stay for patients with SCD presenting with vaso-occlusive pain at a single academic medical center.

Methods: We conducted a retrospective chart review study of adult patients with sickle cell disorders (N = 65) at our academic medical center from January 1, 2023, through March 31, 2024. We assessed charts for patient characteristics, including genotype, gender, and age. We evaluated the availability of acute and chronic pain plans, number of ED and outpatient visits, time to administration of pain medication in the ED, and length of hospital stay for admissions related to vaso-occlusive pain. We calculated ED reliance as the proportion of health care visits occurring in the ED rather than in an outpatient setting. Patients with sickle cell trait were excluded from the final analyses. Data were analyzed using Mann-Whiney U analyses comparing groups.

Results: Approximately 46% of adult patients with SCD (genotypes HbSS, HbSC, HbS-Beta Thalassemia) had an acute or chronic pain plan documented in their chart, most often in a hematology clinic visit note during the study period. Patients with a chronic pain management plan had, on average, significantly more ED visits compared to patients without a chronic pain plan (5.00 visits vs 2.15 visits; U = 654, p = 0.01125). However, mean ED reliance was significantly lower in the group with chronic pain plans than in the group without (0.47 vs. 0.84; U = 643.5, p = 0.01756). Patients with acute pain plans had a longer mean time to receive the first pain medication in the ED than those without acute pain plans; however, this difference was not statistically significant (94.35 minutes vs 68.71 minutes; U = 87, p = 0.1719). The average hospital stay for vaso-occlusive episodes was longer in the acute pain plans group than those without acute pain plans. This difference was also not statistically significant (9.49 days vs. 4.92 days; U = 80.5, p = 0.1003).

Conclusion: Implementation of individualized pain management plans for SCD patients has previously demonstrated decreased ED reliance, decreased time to first pain medication administration, and shorter length of hospital stay. Chronic pain plans did correlate to lower ED reliance in our study despite more frequent ED visits, which may mean that patients are better able to manage their pain at home with appropriate outpatient guidance. Acute pain plans were not attributable to a shorter time to pain medication administration or length of hospital stay. At our institution, clinicians primarily documented pain plans for patients with severe phenotypes. Longer times for pain medication administration may lead to inadequate pain capture in the ED and, therefore, longer hospital stays for patients with a severe phenotype. Several patient, clinician, and system-level factors must be optimized for pain plans to impact outcomes measures favorably. Preliminary root cause analysis conducted in follow-up to these results suggests that pain plans embedded in hematology clinic notes are not easily accessible to critical stakeholders, including ED clinicians. These data indicate that pain plans, though recognized as a strategy to improve SCD care, require thoughtful integration into clinical practice to be effective.