Day-care management of sickle cell painful crisis in Jamaica: a model applicable elsewhere?

In the U.K. and the U.S.A., painful crises account for 80-90 percent of sickle-related hospital admissions, with average durations of 5-11 d. In Jamaica, many severe painful crises are managed in a day-care centre. Patients (n = 1160) with homozygous sickle cell (SS) disease aged 18 years and over were registered with the clinic during a 1-year study period. Of these, 216 patients with 476 painful crises attended the day-care facility for a total of 688 d. Most patients (119 or 55.1 percent) had single crises and for most crises (338 or 71 percent), patients attended for only 1 d, when they were given bed rest, assurance, rehydration and analgesia. Patients with complicated painful crises were usually referred for admission after initial pain relief and the rest were monitored during the day. In the evening they were given the option of hospital admission or allowed home with oral analgesia. Hospital admission for complicated painful crises or inadequate pain relief occurred in 42 (8.8 percent) crises and home management in 434 (91.2 percent) crises. Of 186 patients initially selecting home management, 20 percent returned for further day-care and five (2.7 percent) died during subsequent admission for that painful crisis, one without other known complications, two with acute chest syndrome (one associated with Salmonella septicaemia), another with Salmonella septicaemia, and one with dengue haemorrhagic fever. With suitable oral analgesia, adequate education and support, the majority of severe painful crises in SS disease in Jamaica have been managed on an outpatient basis. This model of patient care may merit assessment in other communities where painful crises are a common clinical problem.(Au)

Outpatient management of the painful crisis in homozygous SS disease: trends and outcomes - abstract

The painful crisis of sickle cell disease is a major cause of recurrent morbidity normally managed by hospital admission. The MRC Laboratories Sickle Cell Unit has been exploring possiblities of outpatient management and the experience in a day care centre over a one-year period (1/4/95 - 31/3/96) is reviewed. During this period 597 painful crises of sufficient severity to require narcotic analgesia among 292 patients with homozygous sickle cell (SS) disease received treatment. Attendances within a 7-day period were arbitrarily considered the same crisis and those separated by more than 7 days as separate crises. There were 146 (50 percent) males and ages ranged from 3.3 - 50.1 years. Single painful crises occurred in 169 patients, 2 crises in 54, 3 - 5 crises in 66, 6 - 9 crises in 9, and more than 9 crises in 4 patients. A cyclical model was found to fit both the monthly attendances and meteorological temperature data for the same period. Fever exceeded 39§C in 11 patients (3 acute chest syndrome, 1 Haemophilus influenza septicaemia, 1 infected leg ulcer; 6 had sterile blood cultures and no apparent cause other than painful crisis). By 3pm patients were given the option of admission or discharge. 25 patients (8.9 percent) with 30 crises were admitted to hospital and 267 patients (91.4 percent) with 567 crises were discharged with oral analgesia. It is proposed that outpatient management of painful crises is feasible, selected by the great majority of patients, and can markly reduce demands on inpatient services. (AU)