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The Gang is All Here!

Managing Pain in Patients with Sickle Cell Disease

Steven Tremain, MD, FACPE

March 5, 2019

Alabama Hospital Association

Objectives

▪ Identify Causes of Pain in SSD

▪Describe misconceptions and biases that serve as barriers to optimal pain management during vascular occlusive crises (VOC) as well as intervals between crises

▪ List various modalities and medications that may lessen the need for opioids while simultaneously improving pain management

Key Points

▪VOC are the hallmark of SCD

▪Causes underlying VOC are complex and not well understood

▪Pain management strategies are insufficient in managing pain

▪Newer treatments are being explored that have the potential to increase the quality of life of SCD patients

▪ Labelling SCD patients as “drug-seeking” is a major barrier to optimal treatment

Pain Management Mainstays

▪Opioids▪ Opioid tolerance

▪ Opioid induced hyperalgesia

▪NSAID

▪But…▪ No change in decades

▪ Inadequate

VOC Triggers

▪Hypoxemia

▪Stress

▪ Trauma

▪ Inflammation

▪ Increased blood viscosity

▪Dehydration

▪Exposure to cold

Principles of VOC Management

▪Analgesic therapy begins within 30-60 minutes of registration▪ QI metric

▪Mild to moderate pain: NSAIDS▪ Continue if relief occurs

▪Severe or no relief from NSAIDs: Parenteral opioids▪ Around the clock with PCA

▪ Avoid troughs

Principles of VOC Management

▪ IV Hydration ▪ No consensus on fluid although hypotonic fluids may be better

▪ Avoid over-hydration, but guidelines of fluid volume do not exist

▪Adjunctive tools▪ Heat

▪ Distractive tools (more on that later)

▪No longer recommended▪ Meperidine

▪ Erythrocyte transfusions

Optimal Pain Management

▪Rapid triage

▪Early analgesia

▪Use of pain management protocol▪ 95% of dosing subtherapeutic

▪Monitoring of sedation▪ Pasero opioid-induced sedation scale

▪Aggressive multi-modal management

Non-Opioids

▪NSAIDs are first line and should be administered in advance of going to the hospital▪ Think ASA for chest pain in potential MI patients

▪ IV ketorolac

Opioids

▪ If pain not controlled by NSAIDs at home or in the hospital then use parenteral opioids (strong evidence)

▪Any available IV opioid (except meperidine) is acceptable▪ Base choice on the individual patient’s co-morbidities and prior

response patterns

▪Oral opioids should only be used in outpatient setting or in the hospital with very low pain intensity that responds

Add SCD to your ED “Time = Outcome” List

▪ The reduction of time to opioid administration significantly impacts pain outcomes

▪ Think Chest Pain: Time to Thrombolytics

▪ Think Trauma: The Golden Hour

Newer and Future Therapies

▪Buccal or intranasal fentanyl

▪ Tramadol

▪Nalbuphine (opioid, first line treatment in France)

▪Ketamine (IV or oral)

Under Study

▪Under study

▪Gabapentin (blocks neural pain pathways)

▪Sevuparin (improves blood flow in mice)

▪Crizanlizumab (decreases cellular ‘stickiness’)

▪Apixaban (factor Xa inhibitor)

▪Statins (have anti-inflammatory effect)

▪Cannabinoids (decrease pain in mice)

No Benefit

▪No Benefit

▪Magnesium

▪Rivipansel

▪Erythrocyte transfusions

▪Prasugrel

Non-Pharmacologic Modalities

▪ TENS

▪Cognitive Behavioral Therapy

▪Massage

▪Biofeedback

▪Hypnosis

▪Virtual Reality

Prevention

▪Hyroxyurea

▪Should be continued during VOC

Conclusions

▪ The pain is real

▪ Treat it promptly

▪Use multi-modal therapy

https://www.ncbi.nlm.nih.gov/pubmed/28853040

Reducing Readmissions forPatients with Sickle Cell Disease

Pat Teske, MHA, RN

March 5, 2019

Alabama Hospital Association

Objectives

▪ List risk factors associated with Sickle Cell readmissions

▪ Discuss strategies to reduce readmissions for patients with Sickle Cell Disease

▪ Plan a test of change for one idea to reduce Sickle Cell readmissions

Risk Factors for Sickle Cell Readmissions

Prior HospitalizationsPatients with fewer than 5 hospitalizations in the previous year had 18% frequency of readmission in 30 days.

Patients with 5 or more hospitalizations in the previous year had a readmission frequency of 75%.

The American Journal of Medicine 2017 130, 601.e9-601.e15DOI: (10.1016/j.amjmed.2016.12.010)

Risk Factors for Sickle Cell Readmissions

No Primary Care Physician▪ The top curve shows patients that did

not have a primary care provider (PCP) during the time of the study, and the bottom curve shows patients that had a PCP.

▪ Patients without a PCP required about 3 fewer hospitalizations to be predicted to have a readmission.

The American Journal of Medicine 2017 130, 601.e9-601.e15DOI: (10.1016/j.amjmed.2016.12.010)

Questions for you?

▪How many patients do you have with Sickle Cell Disease?

▪How often are these patients readmitted?

Small number of patients with SCD

High number of readmissions

Reducing readmissions

for pts. with > 4 admissions /12

months

▪ Think differently

▪ We can make an impact

▪ No more non-compliance

▪ Whole person care – Not just medical

▪ Act differently

▪ Identify

▪ Determine drivers of utilization

▪ Do something different

▪ Plan for their return

▪ Implement Successfully

▪ AIM

▪ Monitor

▪ Action periods

Otherwise it’s groundhog day all over again

Methods of Identification

• Goal is real time identification when the patient arrives

• Flags

• Alerts

• Banners

• Lists

• Ideally automated

Drivers of Utilization

• Goal is to understand why this patient is using the hospital so frequently when others with similar conditions do not

• Interview

• Listen

• Ask why, why, why, why, why?

• ObserveMaxwell, John C. Everyone Communicates, Few Connect: what the most effective people do differently. Thomas Nelson, 2010

Do Something Different

What does something different look like?

▪ Extensive outreach and engagement;

▪ Initial whole person assessment;

▪ Goal setting (What matters to you?)

▪ Care plan development;

▪ Health education/coaching;

▪ Frequent care team contact;

▪ Follow-up with patients after discharge;

▪ Direct linkages to housing, substance use disorder services, and other community resources

▪ Encouraging self-advocacy and personal accountability

http://www.chcs.org/media/HNHC_CHCS_LitReview_Final.pdf

Match the DOU(s) with the plan

If/Then

If DOU is

• Chronic instability

Then

• Work to stabilize

• Patient goal setting

• ED care alert

Plan for Their Return

www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html - Tool 13

www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html - Tool 13

Celebrate small successes!!!

Pat Teske, MHA, RN

Implementation Officer,

Cynosure Health

pteske@cynosurehealth.org

Engaging Patients and Families with Sickle Cell Disease for Better Quality of Life

Martha Hayward

PFE Subject Matter Expert, HRET

The Big Takeaway

To

For

WITH

Partnering with Family Members

Caregivers

are our most

underused

resource

Family

▪ Family is defined by the patient!

▪ Family is our greatest resource.

▪ Family has the the most information.

▪ Family has the most to gain and the most to lose.

▪ Family will be taking on ALL the tasks at home.

▪ Family is more lucid than the patient.

44

The Cycle of Frustration

“Headaches

“Can’t get them to be compliant”

“Their expectation is more Dilaudid”

“Almost all addicted”

“I coerce them the best I can”

“When I see her I want to run”

“They are wasting time I could be with another patient”

Implicit Bias

▪Bias v. Predjudice

▪We define implicit bias as “the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.” The keyword here is "unconscious." We do not set out to discriminate, make others feel “less than” or make poor decisions.

Addiction

▪Personal experience

▪Manipulation

▪Denial

▪Burnout

What Matters to You?

n engl j med 366;9 nejm.org march 1, 2012

Enhancing conversations between

patients and clinicians from --

“What’s the matter?” to also

including “What matters to you?”

What Matters Most?

How might you change you behavior?

• Sit

• Eye contact

• Warm ‘Hello’

• Introduce yourself

• Speak after patient

• Smile

• Ask, don’t tell

Community Resources

▪AuntBertha.com

▪211.org

The voyage of discovery

is not in seeking new landscapes

but in having new eyes.

Marcel Proust

Contact

▪Martha Hayward

▪mhayward2@comcast.net

Thank you for joining us for the webinar today!

If you would like 1.0 Nursing CEUs for today’s webinar, please email mborders@alaha.org to receive the link to the evaluation required for credit.

(https://www.surveymonkey.com/r/7PFV3TB)