What is Sickle Cell Disease?

1. Pain Management in Sickle Cell DiseaseAllan Platt, PA-CThe Georgia Comprehensive Sickle Cell Centerat Grady Health System

2. What is Sickle Cell Disease? • Genetic disorder of hemoglobin • Complications due to hemolysis, vessel occlusions from misshapen RBCs & adhesion, infections, organ failure, and pain episodes • Gene is common in Africa, Middle East, Mediterranean Basin, and India • Detection, education, preventive health care can save lives

3. Why Start a Center? • Prior to 1984 all patients seen in the ER • Erratic care, no continuity, poor pain management • Long waits for care • Many hospitalizations, Many ER visits, Many patient complaints • No comprehensive care • High Cost, High Acuity

4. Objectives of the Sickle Cell Center • 1. 24 Hour Urgent Care • 2. Comprehensive Primary Care • 3. Multidisciplinary Team • 4. Tertiary Care • 5. Education • 6. Research • 7. Disease Management • 8. Worldwide Resource

5. Multidisciplinary Team • PA/NP/MD as Consistent Providers • Newborn Screening Coordinator • RN/LPN as Care Managers, Teachers • SW / CNS-Psych as Support Team • Multimedia Vocational Rehabilitation • Techs/Clerical - Patient Advocates • Consultants - Eye, Nutrition, Audiology, Child Psychiatry, Physical Therapy

6. 24 Hour Urgent Care • Over 15 years old, non-pregnant, non-trauma • MD-PA, RN, Clinic Assistant Model • Problem Specific Clinical Guidelines Developed over 15 years • Aggressive Pain and Fluid Management • 8 Hours of Treatment until Admit Decision • Online Information - Instant Medical Records

7. Treatment of Pain Episodes • Step wise - multimodal approach with parenteral agents and pain assessment • Evaluate to determine cause of pain • Bed rest, quiet environment • Hydration: IV D5W or oral • Analgesics • NSAIAs - Ketorolac • Agonist Narcotics - Morphine • Agonist-Antagonist - Nalbuphine • Adjuvants - Hydroxyzine

8. Guidelines - Online • World Wide Web Site - The Sickle Cell Information Center • http://www.emory.edu/PEDS/SICKLE • Information for providers, patients, teachers, employers, administrators • 2 online books • 19,000 hits a day • 10 email questions a day

9. 10 year data 1991 - 2001 • 20,968 pain episodes • 1,076 patients over 15 years old • Average age 36.8 years old • oldest patient 82 • 51% male, 49% female visits • Pain Assessment using VAS • Admission if: • Complication: Fever, infiltrate, hct… • Return within 48 hours • Pain not manageable after 8 hours

10. 8 Hour Treatment - 20,968 episodes over 10 years 20% Admitted, 80% went home 3988 Admissions + 52 Left AMA + 92 Critical Care

11. Pain Score - Patients going home Pain-in 8.2 Pain-out 4.1

12. Pain Score - Patients Admitted Pain-in 8.8 Pain-out 7.7

13. Active Patients - Admissions

14. Pain Crisis - Admissions

15. Pain Crisis Episodes and Admissions per Active Adult Pain Episodes per active adult Case Management 3.1 Pain 0.5 Admit

16. Impact of Frequent Visitors vs. Active Adults

17. Analgesics Used in 20,968 Pain Episodes in 1,076 Adults Demerol Nubain was used in 57% of pain episodes

18. Teach Patients and Parents Early Prevention Early Treatment Early Screening Better Education Better Pain Management Prevent Complications A cure for all THE FUTURE