In a striking revelation published in the online open-access journal Blood Advances, a recent study investigates the critical issue of emergency department (ED) triage practices for individuals living with sickle cell disease (SCD) undergoing vaso-occlusive crises (VOC). This research uncovers a significant and concerning discrepancy between existing national guidelines and actual clinical practice, highlighting that most patients presenting with VOC are not being assigned the appropriate emergency severity index (ESI) score. This misclassification has profound implications for the timeliness of pain management, underscoring a pressing need for systemic change in acute care protocols for this vulnerable population.
Sickle cell disease, the most prevalent inherited red blood cell disorder in the United States, affects approximately 100,000 individuals, with a disproportionate impact on African American communities where one in every 365 births is affected. The disease is characterized by the production of abnormally shaped hemoglobin S, leading to the classic sickle-shaped erythrocytes. These malformed cells obstruct microvascular blood flow, precipitating episodes of intense ischemic pain, or VOC, which not only cause severe discomfort but also elevate the risk of end-organ damage and infection, making timely and effective pain management essential in emergency care settings.
The study, led by Dr. Abdulaziz Abu Haimed at the University of Maryland Medical Center, scrutinizes the adherence to the National Heart, Lung, and Blood Institute (NHLBI) and American Society of Hematology (ASH) guidelines concerning the assignment of ESI scores and corresponding pain treatment timelines. The ESI is a standardized triage tool used across emergency departments in the U.S., ranging from 1, denoting the highest urgency, to 5, marking the lowest. For patients with VOC, guidelines recommend an ESI score of 2, signifying a high-acuity case meriting rapid intervention, with expectations for the first analgesic dose within an hour of arrival.
Through a retrospective examination of 125 sickle cell-related emergency visits over six months, the researchers isolated 66 VOC visits, excluding those complicated by coexisting conditions requiring similar urgent care levels. The patient cohort, predominantly experiencing the HbSS genotype—the most severe variant—featured a median age of 33 and a high self-reported pain rating of nine out of ten at triage. Intriguingly, only 34.8% of visits were assigned an ESI score of 2, while the majority, 65.2%, received a less urgent ESI 3 designation. This discrepancy likely contributed to substantial delays in pain management.
Analysis revealed a stark contrast in the median time to first analgesic administration between patients accorded with the recommended ESI 2 and those triaged with ESI 3. Individuals classified as ESI 2 received their first dose after a median wait of 65 minutes, a timeframe still surpassing the NHLBI-recommended 60-minute target. By contrast, those assigned ESI 3 faced a median delay of 178 minutes—nearly triple the guideline threshold—with some patients leaving without receiving any pain medication after extended waiting times exceeding 300 minutes. These findings illuminate a glaring gap between recommended best practices and real-world emergency care delivery.
The ramifications of such delays in analgesic administration are particularly troubling given the excruciating nature of VOC pain. As noted by hematologist-oncologist Dr. Jennie Law, VOC episodes are frequently described by patients as the most intense pain of their lives, drawing comparisons to tightening a tourniquet on a limb. Effective and rapid pain control is not merely a comfort measure but a critical component of preventing the exacerbation of ischemic injury and subsequent morbidity. Delays can compound suffering and may lead to adverse patient outcomes, including increased risk of hospital admission and longer inpatient stays.
This study’s design, while rigorous, is not without limitations. Conducted at a single urban tertiary care hospital, its generalizability to other settings remains to be validated, especially in rural or less resourced emergency departments. Additionally, by calculating time to analgesia from triage rather than arrival, the analysis potentially underestimates total waiting periods experienced by patients. Nonetheless, the internal consistency of the data firmly supports the conclusion that inappropriate ESI assignment is a pivotal factor influencing treatment delays.
The research team proposes future investigations with larger, multi-center cohorts to corroborate these findings and explore the broader impact of ESI scoring on patient satisfaction and hospitalization metrics. There is anticipation that such evidence could galvanize policy revisions and resource allocation aimed at streamlining and standardizing VOC management protocols. Furthermore, integrating facility-level quality measures specific to sickle cell VOC management into national health metrics, as advocated by the ASH in partnership with the Health Services Advisory Group, may further enhance accountability and care quality.
Despite the advocacy efforts, these critical quality measures were not incorporated into the proposed FY 2025 Hospital Inpatient Prospective Payment System rule. This exclusion underscores the ongoing challenges in translating research insights into policy and practice improvements. Continued collaboration among clinicians, researchers, and policymakers is imperative to surmount these hurdles and ensure that all patients with sickle cell disease receive equitable, timely, and evidence-based emergency care.
From a clinical perspective, this study illuminates a simple yet impactful intervention: assigning the appropriate ESI score of 2 can dramatically reduce the time to first analgesia—a small procedural change with potential far-reaching benefits. Emergency department staff training and protocol adjustments to align with established guidelines could be pivotal steps toward improving care delivery and patients’ overall emergency department experience.
Moreover, this research brings to light the broader issue of systemic barriers affecting sickle cell disease management, including potential biases and misconceptions in clinical assessment that might contribute to under-triage. Addressing these factors requires comprehensive educational initiatives and institutional commitment to equity in healthcare provision.
In conclusion, as the burden of sickle cell disease continues to affect tens of thousands of Americans, refining emergency care strategies, particularly in pain crisis management, remains paramount. This groundbreaking study offers compelling evidence that adherence to established triage guidelines can markedly enhance the timeliness of pain relief for patients enduring VOC, providing a critical foundation for ongoing efforts to optimize emergency department care for this often underserved population.
—
Subject of Research: The impact of Emergency Severity Index (ESI) assignment on time to pain medication administration in patients with sickle cell disease presenting with vaso-occlusive crisis in emergency departments.
Article Title: Use of Emergency Severity Index 2 Reduces Time to First Analgesia in Sickle Cell Disease Vaso-occlusive Crisis
News Publication Date: October 8, 2025
Web References:
– https://doi.org/10.1182/bloodadvances.2025016538
– https://www.nhlbi.nih.gov/health-topics/evidence-based-management-sickle-cell-disease
– http://www.bloodadvances.org/
– http://www.hematology.org/
