Possible Assessments for Devon
Consider each in the context of a 0-5 Likert scale:
0 – outside perceived professional scope of practice
1 – Strongly agree
2 – Agree
3 – Neutral / unable to determine
4 – Disagree
5 – Strongly disagree
- Acute vaso-occlusive pain secondary to Sickle Cell Disease with chronic, musculoskeletal pain arising from degenerative hip disease. No aberrant drug taking behaviors noted on chart or PDMP review.
- Acute vaso-occlusive pain secondary to Sickle Cell Disease with chronic, musculoskeletal pain arising from degenerative hip disease. Pseudoaddictive behaviors noted likely due to poorly controlled chronic pain and potential lack of primary care provider oversight of severity and impact of persistent pain.
- Sickle Cell Disease with overt drug seeking behaviors and likely substance abuse disorder.
Goals of Care (both acutely and ongoing)
Consider each in the context of a 0-5 Likert scale:
0 – outside perceived professional scope of practice
1 – Strongly agree
2 – Agree
3 – Neutral / unable to determine
4 – Disagree
5 – Strongly disagree
- Reduce acute pain severity by 30-50%
- Decrease need for break through pain medications
- Minimize adverse effects of medications used to treat pain
- Management of future vaso-occlusive episode
- Prevention of infection
- Reduction in emergency medicine utilization
- Prevention of future vaso-occlusive acute pain episodes / complications?
- Prompt discharge from the emergency department
- Limit opioid medication exposure
- Treatment for substance abuse disorder before pain addressed
- Facilitate transfer to local sickle cell disease clinic to improve disease management
- Assistance with establishing with a primary care manager / provider
- Explore denial of disease and non-adherence as possible causes of repeat admissions
- Develop individualized treatment plan card for patient to present when presenting for future acute pain episodes
Plan
Consider each in the context of a 0-5 Likert scale:
0 – outside perceived professional scope of practice
1 – Strongly agree
2 – Agree
3 – Neutral / unable to determine
4 – Disagree
5 – Strongly disagree
- Oxygen per nasal catheter at 2 liters/minute
- Administer 1-2 liters of normal saline, monitor hemodynamics
- Administer 30mg of intramuscular ketorolac
- Administer 30mg of intravenous ketorolac
- Decline opioid therapy due to illicit drug use
- Counsel patient on illicit drug use
- Ignore illicit drug use
- Administer 1.0mg of lorazepam intramuscularly
- Administer 0.5mg of hydromorphone intramuscularly
- Administer 0.5mg of hydromorphone intravenously
- Administer 1.0mg of hydromorphone intravenously
- Administer 2.0mg of hydromorphone intravenously
- Initiate fentanyl intravenous patient controlled analgesia (10mcg / hour basal rate, 20mcg on demand with 8 minute lockout)
- Reassess pain every 15 minutes and re-administer analgesic if required
- Reassess pain every 30 minutes and re-administer analgesic if required
- Reassess pain 60 minutes and re-administer analgesic if required
- Consult social work or nurse case manager to assist with procuring primary care services as well as sickle cell specialty services for patient
- Consult behavioral health service for substance abuse and possible addiction treatment
- Discharge from ED
- Admit to hospitalist / internist service
- Consult pain management service
- Discharge patient with patient education information on sickle cell disease and vaso-occlusive crisis prevention
- Increase hydroxyurea dose
- Change celecoxib to naproxen for discharge
Interprofessional Care of Devon’s Acute and Chronic Pain
Pharmacist
Counsel patients about appropriate use of medications (scheduled vs prn, side effects, etc), Screen for potential drug interactions. Recommend medications (ie selection of medication, dosing)
Nurse
Patient assessment with ongoing monitoring of symptoms, emotional and comfort support needs, development care needs, transitional care planning, patient advocacy, and diagnostic specific interventions.
Physician / Advanced Practice Nurse / Physician’s Assistant
Achieves reduction in patient pain prior to discharge; using teach back method and non-medical vocabulary, instructs patient on pain control measures to be followed at home, provides contact information for nearest local sickle cell disease specialty clinic, especially important given patient’s repeat ED admissions.
Social Worker
Assess the patient and his family using the bio-psycho-social-spiritual model; intervene appropriately during the assessment to engage Devon and his family in a process that partializes the aspects of Devon’s developmental stage in the context of living with sickle cell disease and consequent pain crises. Incorporate developmental and family aspects into overall care plan in consultation with interprofessional team and refer as appropriate.
Psychologist
Interaction with patients hospitalized for a sickle cell crisis on a consultative basis. The initial consultation will focus on a standard assessment of pain severity, but will then move into a more detailed investigation of the impact of pain on current functioning and on the patient's psychological status.
Disparate Care
Devon is at risk for disparate care for his pain based on his race. Each of the following citations includes a brief description of examples of treatment disparities and potential methods for addressing this phenomenon
- Institute of Medicine of the National Academies of Science. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, D.C.: National Academies Press, 2003.
- This seminal book reviewed evidence for disparities across the range of healthcare, finding disparate practices that had resisted change.
- Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB, et al. The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain Medicine 2003;4:277-294.
- This article followed closely on the IOM book, identifying widespread disparities in pain treatment across multiple conditions and addressing topics for research.
- Burgess DJ, van Ryn M, Crowley-Matoka M, & Malat J. Understanding the provider contribution to race/ethnicity disparities in pain treatment: insights from dual process models of stereotyping. Pain Medicine 2006;7:119-134.
- This article framed pain disparities within a dual process model of cognition that emphasized the likely contribution of unconscious processes (e.g., stereotyping).
- Cooper LA, Roter DL, Carson KA, Beach MC, Sabin JA, Greenwald AG, & Inui TS. The association of clinician’s implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health 2012;102: 979-987.
- This article demonstrates the effects of implicit racial bias on patient-provider dynamics within a medical visit.
- Meghani SH, Polomano RC, Tait RC, Vallerand AH, Anderson KO, & Gallagher RM. Advancing a national agenda to eliminate disparities in pain care: Directions for health policy, education, practice, and research. Pain Medicine 2011;13:5-28.
- This article summarizes the current status of racial/ethnic disparities in pain care and points to strategies, including aspects of the Affordable Care Act, that might be mobilized to impact disparities in pain care favorably.
Evidence-Based Practice Guidelines for the Management of Acute Pain Due to Sickle Cell Disease
- National Institute for Health and Clinical Excellence (NICE). Sickle cell acute painful episode: management of an acute painful sickle cell episode in hospital. London (UK): National Institute for Health and Clinical Excellence (NICE); 2012 Jun. 25 p. (NICE clinical guideline; no. 143).
- This 2012 guideline details appropriate management of acute pain from sickle cell disease. Appropriate clinical assessment of pain and pharmacological interventions are covered for populations including children, adults and pregnant women. Additionally, assessment of acute complications is addressed in the guidelines. Intended users of the guideline include nurses, pharmacists, physicians, emergency medical personnel and other healthcare professionals in hospital settings.
- Rees DC, Olujohungbe AD, Parker NE, Stephens AD, Telfer P, Wright J; British Committee for Standards in Haematology General Haematology Task Force by the Sickle Cell Working Party. Guidelines for the management of the acute painful crisis in sickle cell disease. Br J Haematol. 2003 Mar;120(5):744-52.
- This 2003 British guideline provide advice regarding basic care for patients with an acute painful episode from sickle cell disease. Rapid assessment, adequate analgesia and monitoring for acute complications are covered. Non-pharmacologic pain management options, specifics to nursing care are highlighted. Some guidance is also provided for pediatric and pregnant patients.
- Benjamin LJ, Dampier CD, Odesina V, et al., American Pain Society. Guideline for the Management of Acute and Chronic Pain in Sickle Cell Disease, 1999.
