Transforming Emergency Department Care for Sickle Cell Patients

1. CHANGING THE CLIMATE OF CARE IN THE EMERGENCY DEPARTMENTCheryl Brewer, PhD, MSN, RNAssociate Vice President NursingDuke Private Diagnostic ClinicsInternational Association of Sickle Cell Nurses & Professional AssociatesSeptember 5, 201911th Annual Sickle Cell Disease Educational Seminar San Diego Marriott Mission Valley San Diego, California

2. DISCLOSURES I have no actual or potential conflict of interest in relation to this program/presentation.

3. Objectives • Describe Duke Health Emergency Department treatment protocol for Sickle Cell patients • Describe the ED-SCANS framework and practice integration for improving SCD care • Discuss initiatives to improve outcomes for individuals with SCD in the Emergency Department • Report on pathways and strategies to improve ED nursing care for SCD patients

5. Duke Health Emergency Departments • Duke Hospital-1124 beds, regional emergency trauma center • Duke Regional Hospital-335 beds acute, community – 8 counties community/tertiary care • Duke Raleigh Hospital-186 beds acute, community – 2 counties

6. National Heart Lung and Blood Institute. Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014. In: National Institute of Health, ed.: National Institute of Health 2014. Retrieved on March 11, 2015, from http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines

7. Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS) • Research-based QI Framework • Addresses complexity of caring for SCD pts in ED • Seven decisions guide care for adults with SCD • Algorithms support inter-professional collaboration and resources for best practice Tanabe, P., Thornton, V.L., Martinovich, Z., Todd, K., et al. (2014), The Emergency Department sickle cell assessment of needs and strengths (ED-SCANS): Reliability and Validity. Journal of Advanced Emergency Nursing, 35(2), 143-153.

8. Decisions That Guide Care for SCD Patients in the ED

9. Duke Health Emergency Department Treatment Plan for SCD • Patients present with VOP-Pain treatment as quickly as possible. • When treatment area placement not possible, pt followed by Adult SCD team, will receive oral or IV med per IPM Plan. • Pt receives explanation (script available) • Orders entered via “ED Sickle Cell Crisis Set”-EPIC EHR

10. Duke Health Emergency Department Treatment Plan for SCD • Triage nurse administers analgesic • If IV access delayed, pt will receive SubQ Opioid injection. • Pt’s pain re-evaluated after 1 hour • Opioids may be ordered every 1 hr X 3 doses PRN

11. Strategies that Enhance SCD Management • ED Nursing and Medical Leadership support • Sickle Cell Champion program • Advocates • Education dissemination to staff (orientation of new staff, ongoing, and about QI initiatives) • Quality improvement projects • Participate and lead the ED SCD QI meeting • ED SCD QI meetings • Multi-disciplinary with ED leadership support and hematology when possible • QI monitoring projects

12. RESOURCES ED Sickle Cell Disease Website Educational resources, algorithms, forms, video clips/simulations, SCD conference speakers, ED-SCANS, references https://sickleemergency.duke.edu/

13. Available to download in the Apple App Store for free. Use password 1234 for general use or email Dr. Nirmish Shah at Nirmish.shah@duke.edu for specialty access

14. Chronic Pain and the Perception of Addiction Clinician and Patient Knowledge Deficit Racism Frequent Visits SCD Stigma Barriers to Care

15. Pathways to Practice Proficiency Improving Nursing care for ED SCD Patients • Education re Care of SCD Pts • Orientation, Training, Competence • SCD Pathophysiology, disease trajectory & complications • Professional Development/Associations (i.e. IASCNAPA) • SCD Conferences/Webinars • Consider mind/body treatment • Re-think Care Delivery Models • Emphasis: Care Coordination, Transition Management, Population Health

17. Pathways to Nurse Practice Proficiency: Improving care for SCD ED Patients • Screen & refer re: psychosocial needs/issues • SCD pain crisis cue recognition • How SCD pts seek care and cope • Cultural competency training • Implicit bias awareness and training • Provide education for individuals with SCD & families for participating in SCD clinical trials

20. Sustainment and Life-long learning • Measure and monitor success/metrics • Continuous validation of skills & competence • Engage staff in new and innovative ways to address unique needs of SCD patients • Ensure evidence-based practice • Sustain strategies for resilience and work-life balance

21. Nurse Colleagues • Pat Corley, RN Health Educator, Nurse Navigator Cayenne Wellness Center, Glendale, CA IASCNAPA • Dr. Coretta Jenerette Associate Dean for Diversity, Equity & Inclusivity / Professor College of Nursing/University of SC Columbia IASCNAPA • Dr. Paula Tanabe Associate Dean for Research Development and Data Science Duke University School of Nursing

23. References Bulgin, D., Tanabe, P., & Jenerette, D. (2018). Stigma of sickle cell disease: a systematic review. Issues in Mental health Nursing, 39(8), 675-686. Freiermuth, C.E., Silva, S., Cline, D.M. & Tanabe, P. (2016). Shift in emergency department provider attitudes toward patients with sickle cell disease. Advanced Emergency Nursing Journal, 38(3), 199-212. Freiermuth, C.E., Haywood, C., Silva, S., et al. (2014). Attitudes towards patients with sickle cell disease in a multicenter Sample of emergency department providers. Journal of Advanced Emergency Nursing, 36(4), 335-347. Hants, W. & Tanabe, P. (2016). Sickle Cell Disease: A review of non-pharmacological approaches for pain. Journal of Pain and Symptom Management, 51(2). 163-177 Jenerette, C.M., Bosny, J. P., Matthie, N., & Girardeau, Y. (2016). Nurses’ attitudes toward patients with sickle cell disease: a worksite comparison. Pain Management Nursing, 16(3), 173-181. Jenerette, C., Brewer, C., & Ataga, K. (2013). Care seeking for pain in young adults with sickle cell disease. Pain Management Nursing, 15(1), 324-330 Jenerette, C.M., Brewer, C.A. & Edwards, L.J. et al. (2013). An intervention to decrease stigma in young adults with sickle cell disease. Western Journal of Nursing Research, 36, 599-619. Jenerette, C.M., Brewer, C.A., Silva, S. & Tanabe, P. (2016). Does attendance at a sickle cell educational conference Improve clinician knowledge and attitude towards patients with sickle cell disease. Journal of the American Society of Pain Management Nurses, 17(3), 226-234. Smith, S.K., Johnston, J., Rutherford, C., Hollowell, R., & Tanabe, P. (2017). Identifying social behavioral health needs in adults with sickle cell disease in the emergency department. Journal of Emergency Nursing,43(5), 444-450.

24. References National Heart Lung and Blood Institute. Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014. In: National Institute of Health, ed.: National Institute of Health 2014. Retrieved on March 11, 2015, from http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines Tanabe, P., Thornton, V.L., Martinovich, Z., Todd, K., et al. (2013), The Emergency Department sickle cell assessment of needs and strengths (ED-SCANS): Reliability and validity. Journal of Advanced Emergency Nursing, 35(2), 143-153. Thornton, V.L., Holl, J.L., Cline, D. et al. (2014). Application of a proactive risk analysis to emergency department sickle cell care. Western Journal of Emergency Medicine, 15(4), 446-458.