Are your sickle cell patients in danger? Follow new pain management guide
Most EDs fail to adequately manage this disease
When a woman with sickle cell disease walked with assistance to one ED complaining of excruciating pain, she was ignored as she waited for hours. The next time an acute pain episode occurred, the patient instructed her husband to tell the triage nurse she was unable to walk.
"That way, they had to bring her in on a stretcher, and she got immediate treatment," says Victoria Odesina, RN, MS, CS, a clinical research nurse at Yale University School of Nursing in New Haven, CT. "The above patient is a professional with a postgraduate degree. It shows you what some sickle cell patients have to resort to."
Unfortunately, the frustration encountered by the patient in the above scenario is not uncommon, says Odesina. "Often, sickle cell patients are treated as drug seekers or thought to be exaggerating their pain," she explains. Failure to give timely, appropriate interventions can lead to complications and even life-threatening conditions, she warns.
A new Quick Reference Guide for Emergency Department Clinicians was developed by the Glenview, IL-based American Pain Society (APS) to address the unique needs of sickle cell patients. The guide gives you specific steps to follow, with instructions for what to do next if pain is not relieved after 10 minutes or complications arise, says Odesina. (To see algorithm for Management of an Episode of Acute Pain in Sickle-Cell Disease, click here. To obtain a copy of the Quick Reference Guide, see "Source and resources" at the end of this article ) "The role of the ED nurse cannot be overemphasized," emphasizes Odesina, who helped to develop the APS’ guidelines for sickle cell pain management. "You play an essential role in the successful management of sickle cell pain episodes."
Here are ways to improve care of sickle cell patients, according to the new guidelines:
• Assure patients that their pain will be relieved.
Sickle cell disease is very difficult to manage; because pain episodes not only vary from one patient to the other, also they can be different from one episode to the next, says Odesina. "So you may have a patient with a history of pain episodes in the legs and back, and next time it may be in the chest or abdomen," she explains. (To see "Common Pain States Associated with Sickle-Cell Disease," click here.)
First, reassure the patient that you understand how to manage sickle cell pain, says Odesina. "If the patient realizes that you know what to do, they have some comfort in knowing that at least they won’t have to beg for the appropriate medication or treatment," she explains. "For sickle cell patients, that’s half the battle, and the stress of worrying can make the pain episode worse."
• Find out if the pain is different from usual.
Ask the patient, "Is this pain your typical crisis pain?" recommends Allan Platt, PA-C, program coordinator of the Georgia Comprehensive Sickle Cell Center at Grady Health System in Atlanta. If the answer is no, quickly seek complications and other causes of pain, Platt emphasizes. "Head, chest, and abdominal pain are all high priority, because they could be the signal of a life-threatening complication or nonsickle cell emergency," he says. "Fever and pain is a red flag also." [See "Sickle cell information center protocols (excerpt)" in this issue.]
• Be sure to reassess pain.
Be familiar with new pain management standards from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, suggests Kim Colonnelli, RN, BSN, MA, director of emergency and trauma services at Palomar Medical Center in Escondido, CA.
Reassessment is required, and surveyors will be looking for this documented in nurses’ notes, she adds. "Reassessment of the patient goes hand in hand with medication administration," says Colonnelli. "Also, nursing notes need to reflect that you have reassessed the patient." Use whatever method was used to assess pain upon the patient’s arrival to ensure consistency in reassessment, she advises.
• Always treat sickle cell pain as an emergency.
Often, sickle cell pain is not recognized as an emergency, but this is a serious mistake, warns Odesina. You need to understand the basic process of vaso-occlusion that is causing the pain, she says. "The earlier you alleviate it, the better the chance of recovery," she emphasizes. Repeated and prolonged vaso-occlusion results in tissue damage, Odesina warns. "That is why you see multiple-organ damage in adult sickle cell patients," she adds. "What you do at any given time has either a positive or negative impact on the patient’s prognosis. That makes sickle cell pain an emergency."
Sickle cell pain might look like ordinary pain, but it might be life-threatening, Odesina cautions. She notes that a sickle cell patient might present with chest pain due to acute chest syndrome or abdominal pain due to splenic sequestration, both of which can be fatal.
• Obtain input from the patient about pain relief.
Sickle cell patients are used to living with chronic pain, so they already will have attempted to manage their acute pain episodes at home for hours or days, says Odesina. "The last place an individual with sickle cell pain wants to be is the ED, because they often don’t get appropriate treatment," she says. "Coming to the ED is their last resort."
At that point, the patient needs immediate pain relief, says Odesina. "This is not a time to worry about addiction," she adds. She recommends assessing the patient’s pain level using age-appropriate pain scales and time frames provided in the guideline. "A misconception is that sickle cell patients fake their pain," she says. "Remember that the patient is the one experiencing the pain, and only the patient can accurately and objectively describe the pain."
When a sickle cell patient requests a specific drug, you might see that as a red flag that the patient is a drug seeker, but this is a mistake, says Odesina. "It actually helps to ask the patient what works for him or her," she stresses.
• Don’t use sedatives and anxiolytics alone to manage pain.
These medications can mask the behavioral response to pain without providing analgesia, says Odesina. If you give a patient morphine, the side effect is drowsiness. The patient may be sleeping, but that doesn’t mean the pain is gone," she adds. Sickle cell patients usually have found ways to adjust and distract themselves, so they may appear stoic, says Odesina. "When they complain, the pain is real," she says. "If they are quiet, that doesn’t mean that their pain is not as bad as a patient who may be screaming and thrashing around."
The guidelines recommend use of nonsteroidal anti-inflammatory drugs or acetaminophen for mild to moderate pain, adding an opioid if it persists, and increasing the opioid strength or dosage as appropriate for moderate-to-severe or persistent pain, says Odesina.
• Advocate for sickle cell patients.
Patients in pain rely on you to advocate for them, says Odesina. "You are the liaison between the patient and the physician, to be sure that the appropriate pain medication is given," she explains. Discuss the use of the guideline with nurses and physicians, hang the chart on the wall of every treatment room, and show the pocket guide to physicians, while pointing out the specific interventions that should be taken, she recommends.
A common problem is that patients aren’t given enough medication to hold them until they can see their regular doctors, says Odesina. "ED physicians often don’t give enough, either in quantity or strength. It should be equivalent to the IV they were given in the ED," she says. "When an inadequate prescription is given, you should question it."
Sources and resource
For more information about sickle cell pain management, contact:
• Kim Colonnelli, RN, BSN, MA, Emergency and Trauma Services, Palomar Medical Center, 555 E. Valley Parkway, Escondido, CA 92025. Telephone: (760) 739-3320. Fax: (760) 739-3121. E-mail: [email protected].
• Victoria Odesina, RN, MS, CS, Yale University School of Nursing, ATHENA Project, 100 Church St., New Haven, CT 06536. Telephone: (203) 737-5082. Fax: (203) 737-4480. E-mail: [email protected].
• Allan Platt, PA-C, Program Coordinator, The Georgia Comprehensive Sickle Cell Center, Grady Health System, Atlanta, GA. Telephone: (404) 616-5994. Fax: (404) 616-5998. E-mail: [email protected].
Copies of the Guideline for Management of Acute Pain in Sickle-Cell Disease: Quick Reference Guide for Emergency Department Clinicians are available from the American Pain Society. A pocket guide costs $7.50 for a package of 10 for members and $9 for nonmembers. A wall chart costs $2 for a single copy for members and $2.50 for nonmembers. To order, contact: American Pain Society, 4700 W. Lake Ave., Glenview, IL 60025. Telephone: (847) 375-4715. Press 3. Fax: (877) 734-8758. E-mail: [email protected].
A web site for the Sickle Cell Information Center features extensive resources for sickle cell patients and health care providers (www.emory.edu/PEDS/SICKLE). For more information or to order the resources by mail, contact: The Sickle Cell Information Center, P.O. Box 109, Grady Memorial Hospital, 80 Butler St. S.E., Atlanta, GA 30303. Telephone: (404) 616-3572. Fax: (404) 616-5998. E-mail: [email protected].
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