Context Matters: Another Example

June 2017

In 2011, the National Institutes for Health released guidelines for the treatment of patients with sickle cell anemia in the emergency department. The guidelines recommended that sickle cell patients presenting with fever receive antibiotics within 60 minutes. Patients presenting with pain needed to be given pain medication within 60 minutes as well. 

Yet when Christopher McKinney​, MD and his team from Children’s Hospital Colorado looked at the data, they found that sickle cell patients requiring antibiotics received treatment within 60 minutes only 20% of the time. Patients requiring pain medication received it within an hour only 50% of the time. 

Meanwhile, these same metrics were being met in the emergency department 90% of the time in a different patient subset: patients with cancer. 

One might assume that the awareness strategies used to disseminate the guidelines for cancer patients could be used with sickle cell patients and receive comparable results. 

“Unfortunately, we’ve seen some disparities in the outcomes we’ve been able to achieve,” said Dr. McKinney, instructor at the Center for Cancer and Blood Disorders. He explains how despite the fact the metrics are the same for both cancer and sickle cell, they’ve been much more successful on the oncology side.

“The goal is the same but we’re learning that we can’t adopt the same strategy for one group and expect it to work in a different patient population.”

David Brumbaugh​, MD, associate chief medical officer of Children’s Colorado, believes Dr. McKinney and his team have chosen the right process metrics to tackle. “They are absolutely right to set their outcome goals to be identical to what we are achieving in our cancer population,” he said. “It remains a challenge in medicine to achieve high reliability in treatment of rare conditions, because you don’t have the learning benefit of repetition.”

Addressing Psycho-Social Differences Between Patient Populations

Because cancer patients typically have central venous lines already, it’s easy for the nursing staff to quickly begin treatment with pain medication and/or antibiotics. But the 220 sickle cell anemia patients treated annually at the CCBD clinic don’t have central lines, so these patients must wait for an IV.  

“Part of the issue is self-identification,” he explains. “We find in children with cancer, their parents will say, ‘my kid has cancer with a fever’ when they present. And often someone from oncology will have already been notified, and they’ll call the ED to let them know the patient is on the way.”

For patients with sickle cell, this self-identification is rare—despite the fact that pain is one of the most common reasons a sickle cell patient presents to the ED. 

“Sickle cell is a blood disorder. Normal blood cells are shaped like donuts, and in sickle cell they are shaped like crescents,” he explains. “The crescents can clog blood vessels, and the most common side effect is severe pain that requires admissions for IV opiates. The pain usually appears in the back, arms, or other extremities, and is often described as ‘sharp and stabbing.’” 

There are other unique factors associated with the sickle cell population. “Sickle cell often impacts lower income minority groups. English may not be their first language, and as with any lower income group, there are psycho-social areas that need to be addressed,” he said.

Developing a Curriculum About Sickle Cell

The very nature of the emergency department, added with the relatively rare incidence of sickle cell patients presenting to the ED, means education of providers is paramount to improving these results. 

“Critical in this process is immediate recognition of the sickle cell patient, through EPIC functionality and family self-advocacy, and front-line education of emergency department care teams, so that treatment can be initiated immediately,” Dr. Brumbaugh said.

Dr. McKinney and his team are already developing a multidisciplinary curriculum to teach people why the sickle cell quality metrics are important, how to address them, and how these metrics are being tracked. In addition to tracking the 60 minute to treatment metric, they will also be tracking the admission rates and length of stay. 

“It’ll be another year before we have any meaningful data,” Dr. McKinney said. “But our goal is to get the percentage of sickle cell patients treated with antibiotics and/or opiates to over 90%, with the hope that these patients experience better outcomes.”

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