Clinical question: Are outcomes better for sickle cell patients experiencing vaso-occlusive crises (VOCs) when treated in an infusion center (IC) rather than an emergency department (ED)?
Background: VOCs are the most common complication of sickle cell disease (SCD), with a high burden of ED care often followed by subsequent inpatient hospitalization. Established guidelines have recommended rapid initiation of analgesia followed by frequent reassessment and redosing to achieve pain control. This can be difficult with the competing acuity of patient care seen in standard EDs. Limited data surrounding ICs, as alternatives to EDs, has shown a decrease in inpatient admissions and improved outcomes, but no direct comparison of EDs versus ICs exists.
Study design: Prospective observational study.
Setting: Four sites in four U.S. cities with both ICs and EDs (Baton Rouge, La., Cleveland, Milwaukee, and Baltimore).
Synopsis: The authors identified participants who had acute-care visits during weekdays to allow for direct comparison of ICs, which have limited hours, compared to traditional EDs. Patients who met the criteria for complicated VOC, including acute chest syndrome, priapism, and stroke, were excluded. The mean time to the first dose of parenteral pain medication was 70 minutes faster in ICs compared to EDs (62 minutes versus 132 minutes, respectively, 95% CI, 54 to 98 minutes; P <0.001; E-value, 2.8). The probability that patients would have their pain reassessed 30 minutes following their first dose of parenteral medication was 3.8 times greater in ICs compared to EDs (CI, 2.63 to 5.64 times greater; P <0.001; E-value, 4.7). The probability that the patient’s evaluation would result in subsequent hospital admission was smaller by a factor of 0.25 in ICs compared to EDs (CI, 0.18 to 0.33; P <0.001; E-value, 5.4).
Bottom line: ICs adhere more strictly to sickle cell patient guideline-based care, including faster time to the first dose of parenteral medication and faster reassessment for continued management. The probability of the patient being admitted is also decreased when managed in an IC.
Citation: Lanzkron S et al. Treatment of acute pain in adults with sickle cell disease in an infusion center versus the emergency department: a multicenter prospective cohort study. Ann Intern Med. 2021;174(9):1207-1213. doi:10.7326/M20-7171.
Dr. Watkins is an assistant professor of medicine, division of hospital medicine, at the Emory School of Medicine, Atlanta.