Emergency Department (ED), ED Observation, Day Hospital, and Hospital Admissions for Adults with Sickle Cell Disease.

INTRODUCTION: Use of alternative venues to manage uncomplicated vaso-occlusive crisis (VOC), such as a day hospital (DH) or ED observation unit, for patients with sickle cell anemia, may significantly reduce admission rates, which may subsequently reduce 30-day readmission rates. METHODS: In the context of a two-institution quality improvement project to implement best practices for management of patients with sickle cell disease (SCD) VOC, we prospectively compared acute care encounters for utilization of 1) emergency department (ED); 2) ED observation unit; 3) DH, and 4) hospital admission, of two different patient cohorts with SCD presenting to our two study sites. Using a representative sample of patients from each institution, we also tabulated SCD patient visits or admissions to outside hospitals within 20 miles of the patients' home institutions. RESULTS: Over 30 months 427 patients (297 at Site 1 and 130 at Site 2) initiated 4,740 institutional visits, totaling 6,627 different acute care encounters, including combinations of encounters. The range of encounters varied from a low of 0 (203 of 500 patients [40.6%] at Site 1; 65 of 195 patients [33.3%] at Site 2), and a high of 152 (5/month) acute care encounters for one patient at Site 2. Patients at Site 2 were more likely to be admitted to the hospital during the study period (88.4% vs. 74.4%, p=0.0011) and have an ED visit (96.9% vs. 85.5%, p=0.0002). DH was used more frequently at Site 1 (1.207 encounters for 297 patients at Site 1, vs. 199 encounters for 130 patients at Site 2), and ED observation was used at Site 1 only. Thirty-five percent of patients visited hospitals outside their home academic center. CONCLUSION: In this 30-month assessment of two sickle cell cohorts, healthcare utilization varied dramatically between individual patients. One cohort had more hospital admissions and ED encounters, while the other cohort had more day hospital encounters and used a sickle cell disease observation VOC protocol. One-third of patients sampled visited hospitals for acute care outside of their care providers' institutions.

High-Resolution Magnetic Resonance Imaging of the Regenerating Adult Zebrafish Heart.

The adult zebrafish is a well-established model for studying heart regeneration, but due to its tissue opaqueness, repair has been primarily assessed using destructive histology, precluding repeated investigations of the same animal. We present a high-resolution, non-invasive in vivo magnetic resonance imaging (MRI) method incorporating a miniature respiratory and anaesthetic perfusion set-up for live adult zebrafish, allowing for visualization of scar formation and heart regeneration in the same animal over time at an isotropic 31 µm voxel resolution. To test the method, we compared well and poorly healing cardiac ventricles using a transgenic fish model that exhibits heat-shock (HS) inducible impaired heart regeneration. HS-treated groups revealed persistent scar tissue for 10 weeks, while control groups were healed after 4 weeks. Application of the advanced MRI technique allowed clear discrimination of levels of repair following cryo- and resection injury for several months. It further provides a novel tool for in vivo time-lapse imaging of adult fish for non-cardiac studies, as the method can be readily applied to image wound healing in other injured or diseased tissues, or to monitor tissue changes over time, thus expanding the range of questions that can be addressed in adult zebrafish and other small aquatic species.

Attitudes toward patients with sickle cell disease in a multicenter sample of emergency department providers.

Patients with sickle cell disease (SCD) often seek care in the emergency department (ED) for pain associated with vaso-occlusive crises. Research has shown that negative provider attitudes serve as a barrier to care in this patient population. Our aim was to validate a survey that measures attitudes toward SCD patients among ED providers (nurses and physicians) and to compare differences in attitude scores between provider types. We administered the general perceptions about Sickle Cell Disease Patients Scale, previously validated among internal medicine providers, and the Medical Condition Regard Scale (MCRS) to ED nurses and physicians from two EDs. A total of 215 surveys were returned (63% response rate, 200 with attitude items completed). Three subscales were identified: Negative Attitudes, Uneasiness With Care, and Positive Attitudes. Cronbach's αs exceeded 0.81 for each subscale. Mean (SD) scores for the Negative, Uneasiness, and Positive subscales and MCRS were 61.5 (20.3), 66.1 (17.1), 41.2 (17.8), and 42.2 (8.9), respectively. Compared with physicians, nurses had significantly higher mean Negative Attitude scores and lower Uneasiness scores. A slightly modified version of the general perceptions about Sickle Cell Disease Patients Scale appears to be a valid measure of ED provider attitudes toward SCD patients. Among ED providers, this scale identified a dimension not observed in research with the original instrument among internal medicine providers. Provider attitudes influence patient-provider interactions and quality of care. The scale we present here has major clinical implications, particularly for advanced practice nurses, who can use the scale not only to assess providers' attitudes toward SCD patients but also to determine the effectiveness of tailored interventions to improve those attitudes.

Application of a proactive risk analysis to emergency department sickle cell care.

INTRODUCTION: Patients with sickle cell disease (SCD) often seek care in emergency departments (EDs) for severe pain. However, there is evidence that they experience inaccurate assessment, suboptimal care, and inadequate follow-up referrals. The aim of this project was to 1) explore the feasibility of applying a failure modes, effects and criticality analysis (FMECA) in two EDs examining four processes of care (triage, analgesic management, high risk/high users, and referrals made) for patients with SCD, and 2) report the failures of these care processes in each ED. METHODS: A FMECA was conducted of ED SCD patient care at two hospitals. A multidisciplinary group examined each step of four processes. Providers identified failures in each step, and then characterized the frequency, impact, and safeguards, resulting in risk categorization. RESULTS: Many "high risk" failures existed in both institutions, including a lack of recognition of high-risk or high-user patients and a lack of emphasis on psychosocial referrals. Specific to SCD analgesic management, one setting inconsistently used existing analgesic policies, while the other setting did not have such policies. CONCLUSION: FMECA facilitated the identification of failures of ED SCD care and has guided quality improvement activities. Interventions can focus on improvements in these specific areas targeting improvements in the delivery and organization of ED SCD care. Improvements should correspond with the forthcoming National Heart, Lung and Blood-sponsored guidelines for treatment of patients with sickle cell disease.

The Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS): reliability and validity.

Emergency department (ED) management of adults with sickle cell disease (SCD) is complex and frustrating. The Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS) is a research-based decision support and quality improvement (QI) tool to guide management of individual patients with SCD and can also be used to guide the development of ED protocols and other QI initiatives for this population. The study evaluated ED-SCANS' inter-rater reliability, face and utility validity among clinicians, and construct validity of anxiety, depression, and psychiatric or social service needs among patients. ED nurses and physicians found the ED-SCANS to be useful, relevant, and easy to use. Nurse practitioners can use the ED-SCANS to assess and manage individual patients. Clinical nurse specialists can use the ED-SCANS as a framework to guide departmental QI efforts.

What is infidelity? Perceptions based on biological sex and personality.

The study examines perceptions of infidelity, paying particular attention to how these perceptions differ based on biological sex and personality traits, specifically agency and communion and their unmitigated counterparts. The study utilizes a sample of 125 male and 233 female college students. In addition to the personality measures, participants completed a 19-item checklist that assessed their perceptions of specific items that could potentially be construed as infidelity. It was hypothesized that females would construe more items as infidelity than would males. It was also predicted that unmitigated communion and communion would be positively correlated with these perceptions and that unmitigated agency would be negatively correlated with these perceptions. No correlation was predicted between agency and infidelity. All hypotheses were supported. Implications and suggestions for future research are discussed.

Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS), a focus group and decision support tool development project.

OBJECTIVES: A decision support tool may guide emergency clinicians in recognizing assessment, analgesic and overall management, and health service delivery needs for patients with sickle cell disease (SCD) in the emergency department (ED). We aimed to identify data and process elements important in making decisions regarding evaluation and management of adult patients in the ED with painful episodes of SCD. METHODS: Qualitative methods using a series of focus groups and grounded theory were used. Eligible participants included adult clients with SCD and emergency physicians and nurses with a minimum of 1 year of experience providing care to patients with SCD in the ED. Patients were recruited in conjunction with annual SCD meetings, and providers included clinicians who were and were not affiliated with sickle cell centers. Groups were conducted until saturation was reached and included a total of two patient groups, three physician groups, and two nurse groups. Focus groups were held in New York, Durham, Chicago, New Orleans, and Denver. Clinician participants were asked the following three questions to guide the discussion: 1) what information would be important to know about patients with SCD in the ED setting to effectively care for them and help you identify patient analgesic, treatment, and referral needs? 2) What treatment decisions would you make with this information? and 3) What characteristics would a decision support tool need to have to make it meaningful and useful? Client participants were asked the same questions with rewording to reflect what they believed providers should know to provide the best care and what they should do with the information. All focus groups were audiotaped and transcribed. The constant comparative method was used to analyze the data. Two coders independently coded participant responses and identified focal themes based on the key questions. An investigator and assistant independently reviewed the transcripts and met until the final coding structure was determined. RESULTS: Forty-seven individuals participated (14 persons with SCD, 16 physicians, and 17 nurses) in a total of seven different groups. Two major themes emerged: acute management and health care utilization. Major subthemes included the following: physiologic findings, diagnostics, assessment and treatment of acute painful episodes, and disposition. The most common minor subthemes that emerged included past medical history, presence of a medical home (physician or clinic), individualized analgesic treatment plan for treatment of painful episodes, history of present illness, medical home follow-up available, patient-reported analgesic treatment that works, and availability of analgesic prescription at discharge. Additional important elements in treatment of acute pain episodes included the use of a standard analgesic protocol, need for fluids and nonpharmacologic interventions, and the assessment of typicality of pain presentation. The patients' interpretation of the need for hospital admission also ranked high. CONCLUSIONS: Participants identified several areas that are important in the assessment, management, and disposition decisions that may help guide best practices for SCD patients in the ED setting.