For patients with less severe pain, options for PRN (pro re nata, or as needed) bolus dose morphine and hydromorphone offer dose ranges that reflect the narcotic tolerance frequently observed in these patients. The order set includes options for non-opiate agents, including ketorolac and acetaminophen. Adjuvant therapies, including promethazine, zolpidem, and diphenhydramine, are also contained within the order set. Prompts for intravenous fluid replacement, oxygen therapy, and other supportive measures are incorporated into the orders as well.
The Novant-SPR hospitals have adopted a separate order set for the administration of pneumococcal vaccine. This order set allows for the automatic administration of pneumococcal vaccine, without a specific physician order, to every patient who meets criteria and who desires the vaccine. On admission, every patient is screened by a nurse regarding their need for pneumococcal vaccine; as a result, SCD patients who have not been immunized in the previous five years are offered the vaccine.
Day Hospital Model
In order to provide SCD patients with immediate and aggressive analgesic therapy and fluid replacement, some centers have adopted the Day Hospital (DH) model. The DH is a specific site at which patients with SCD pain crisis are treated by staff familiar with the patients and with their special analgesic needs.5 The DH model has been shown to provide rapid pain relief in an outpatient setting and to reduce the need for unnecessary hospitalizations. In addition, length of stay and cost per case are lower for DH patients admitted to the hospital than for patients not followed by DH staff. It has been suggested that the DH model is especially appropriate for centers with an emergency department too busy to begin treatment in a timely fashion.6
Novant Health has adopted the DH model in the urgent care setting. Patients with pain crises can be managed in one of Novant’s urgent care centers with a standard order set that includes options for IV hydration as well as parenteral morphine or hydromorphone. This outpatient order set parallels that designed for inpatients, because it prompts the physician to order aggressive analgesic therapy as well as adjuvant treatments for nausea and anxiety. Practitioners from Novant’s Sickle Cell Clinic often meet the patient at the urgent care center to assist with evaluation and management. In the past two years, approximately two-thirds of patients with SCD pain crisis have been discharged to home with good pain relief. The remaining one-third are referred to the hospital—usually to be admitted and managed by the PICS team.
Hope for the Future
It has been more than 50 years since the molecular defect in hemoglobin S was first described by Linus Pauling and 50 years since the genetic defect was first elucidated.7,8 Despite these and subsequent advances in understanding the pathogenesis of SCD at the cellular and molecular level, our treatment for SCD remains inadequate. It is akin to a “halfway technology” described by Lewis Thomas as, “the kinds of things that must be done … in order to compensate for the incapacitating effects of certain diseases whose course one is unable to do very much about. It is a technology designed to make up for disease, or to postpone death.”9
At present a number of agents designed to inhibit the sickling process are under investigation, including omega-3 fatty acids, Gardos channel blockers, and anti-adhesion therapies.10 In time, perhaps, one of these rational approaches to treatment will bridge the chasm in the halfway technology currently at our disposal. TH
Dr. Gardella is a board-certified internist and pulmonologist who currently serves as vice president for clinical improvement for Novant Health—Southern Piedmont Region.