Browsing by Author "Paice, Judith A"

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    A Comparison of the effect of patient-specific vs. weight-based protocols to treat vaso-occlusive episodes (VOE) in the emergency department.
    (Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2023-09) Tanabe, Paula; Ibemere, Stephanie; Pierce, Ava E; Freiermuth, Caroline E; Bosworth, Hayden B; Yang, Hongqui; Osunkwo, Ifeyinwa; Paxton, James H; Strouse, John J; Miller, Joseph; Paice, Judith A; Veeramreddy, Padmaja; Kavanagh, Patricia L; Wilkerson, R Gentry; Hughes, Robert; Barnhart, Huiman X

    Background

    Vaso-occlusive episodes (VOC) cause debilitating pain and are a common cause of emergency department (ED) visits, for people with sickle cell disease (SCD). Strategies for achieving optimal pain control vary widely despite evidence-based guidelines. We tested existing guidelines and hypothesized a patient-specific protocol (PSP) written by their SCD provider, may be more effective than weight-based (WB) dosing of parenteral opiate medication, in relieving pain.

    Methods

    Prospective, randomized controlled trial comparing a PSP versus WB protocol for patients presenting with VOC to six EDs. Patients were randomized to a PSP or WB protocol prior to an ED visit. SCD provider wrote their protocol and placed in the electronic health record for future ED visits with a VOC Exclusion criteria included: pre-existing PSP excluding parenteral opioid analgesia or out-patient use of buprenorphine or methadone, or highly suspected for COVID-19. Pain intensity scores, side effects and safety were obtained every 30 minutes for up to 6 hours post-ED bed placement. The primary outcome was change in pain intensity score from placement in an ED space to disposition or six hours.

    Results

    328 subjects were randomized, 104 participants enrolled (ED visit, target n=230) with complete data for 96 visits. The study was unable to reach the target sample size and stopped early due to the impact of COVID-19. We found no significant differences between groups in the primary outcome; patients randomized to a PSP had a shorter ED length of stay (p=.008); the prevalence of side effects was low in both groups. Subjects in both groups experienced both a clinically meaningful and statistically significant decrease in pain (27 mm on a 0-100 mm scale) CONCLUSIONS: We found a shorter ED length of stay for patients assigned to a PSP. Patients in both groups experienced good pain relief without significant side effects.
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    A randomized controlled trial comparing two vaso-occlusive episode (VOE) protocols in sickle cell disease (SCD).
    (American journal of hematology, 2018-02) Tanabe, Paula; Silva, Susan; Bosworth, Hayden B; Crawford, Regina; Paice, Judith A; Richardson, Lynne D; Miller, Christopher N; Glassberg, Jeffrey
    Limited evidence guides opioid dosing strategies for acute Sickle Cell (SCD) pain. We compared two National Heart, Lung and Blood (NHBLI) recommended opioid dosing strategies (weight-based vs. patient-specific) for ED treatment of acute vaso-occlusive episodes (VOE). A prospective randomized controlled trial (RCT) was conducted in two ED's. Adults ≥ 21 years of age with SCD disease were eligible. Among the 155 eligible patients, 106 consented and 52 had eligible visits. Patients were pre-enrolled in the outpatient setting and randomized to one of two opioid dosing strategies for a future ED visit. ED providers accessed protocols through the electronic medical record. Change in pain score (0-100 mm VAS) from arrival to ED disposition, as well as side effects were assessed. 52 patients (median age was 27 years, 42% were female, and 89% black) had one or more ED visits for a VOE (total of 126 ED study visits, up to 5 visits/patient were included). Participants randomized to the patient-specific protocol experienced a mean reduction in pain score that was 16.6 points greater than patients randomized to the weight-based group (mean difference 95% CI = 11.3 to 21.9, P = 0.03). Naloxone was not required for either protocol and nausea and/or vomiting was observed less often in the patient-specific protocol (25.8% vs 59.4%, P = 0.0001). The hospital admission rate for VOE was lower for patients in the patient-specific protocol (40.3% vs 57.8% P = 0.05). NHLBI guideline-based analgesia with patient-specific opioid dosing resulted in greater improvements in the pain experience compared to a weight-based strategy, without increased side effects.
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    Exploring Emergency Department Provider Experiences With and Perceptions of Weight-Based Versus Individualized Vaso-Occlusive Treatment Protocols in Sickle Cell Disease.
    (Advanced emergency nursing journal, 2019-01) Knight, LaʼKita MJ; Onsomu, Elijah O; Bosworth, Hayden B; Crawford, Regina D; DeMartino, Theresa; Glassberg, Jeffrey; Paice, Judith A; Miller, Christopher N; Richardson, Lynne; Tanabe, Paula
    Treatment of vaso-occlusive episodes (VOEs) is the most common reason for emergency department (ED) treatment of sickle cell disease (SCD). We (1) compared perceptions of the usability and ability to manage VOE pain between ED nurses and other ED provider types, ED sites, and VOE protocols (individualized vs. weight-based), and (2) identified ED nurse and other provider protocol suggestions. A secondary analysis of provider survey data collected immediately after caring for a patient enrolled in a randomized controlled trial comparing weight-based versus individualized opioid dosing for VOE. Research staff asked the ED nurses and other ED providers (nurse practitioners [NPs], physician assistants [PAs], residents, and attending physicians) 5 questions related to the protocol's ease of use and ability to manage pain. There were 236 surveys completed. Attending physicians (n = 15), residents (n = 88), PAs (n = 21), and NPs (n = l) were more satisfied than nurses (n = 111) with the clarity of the analgesic ordering (97.6% vs. 0%, p = 0.0001) and ability to manage the patient's VOE pain (91% vs. 0%, p = 0.0001). When comparing both protocols with the usual ED strategy in their ED to manage VOE, more nurses than other ED providers perceived the study patients' pain management protocol as better (100% vs. 35.2%, p = 0.0001). Other ED providers perceived the individualized versus weight-based protocol as better at managing pain than their usual ED strategy (70.3% vs. 59.5%, p = 0.04). The individualized protocol was perceived as better in managing VOE than the weight-based ED strategy. While physicians were satisfied with the clarity of the protocols, nurses were not. Improved protocol usability is required for widespread ED implementation.
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    Time to pain relief: A randomized controlled trial in the emergency department during vaso-occlusive episodes in sickle cell disease.
    (European journal of haematology, 2023-05) Tanabe, Paula; Bosworth, Hayden B; Crawford, Regina D; Glassberg, Jeffrey; Miller, Christopher N; Paice, Judith A; Silva, Susan

    Objective

    Compare time to pain relief (minimum of a 13 mm and 30% reduction) during an Emergency Department (ED) visit among patients with sickle cell disease (SCD) experiencing severe pain associated with a vaso-occlusive episode who were randomized to receive either an individualized or weight-based pain protocol.

    Methods

    A randomized controlled trial in two EDs. Adults with sickle cell disease. Research staff recorded pain scores every 30 min during an ED visit (up to 6 h in the ED) using a 0-100 mm visual analogue scale. Analysis included 122 visits, representing 49 patients (individualized: 61 visits, 25 patients; standard: 61 visits, 24 patients).

    Results

    Pain reduction across 6-h was greater for the individualized compared to the standard protocol (protocol-by-time: p = .02; 6-h adjusted pain score comparison: Individualized: M = 29.2, SD = 38.8, standard: M = 45.3, SD = 35.6; p = .03, Cohen d = 0.43). Hazards models indicated a greater probability of 13 mm (HR = 1.54, 95% CI = 1.05, 2.27, p = .03) and 30% (HR = 1.71, 95% CI = 1.11, 2.63, p = .01) reduction in the individualized relative to the standard protocol.

    Conclusions

    Patients who received treatment with an individualized protocol experienced a more rapid reduction in pain, including a 13 mm and 30% reduction in pain scores when compared to those that received weight-based dosing.