Depression and Sleep Impairment Impact on Pain and Quality of Life for Sickle Cell Patients

Vaso-occlusive crisis pain is both an acute and chronic factor for patients with sickle cell disease (SCD). Many of the complications associated with SCD have some aspect of pain associated with them, beginning in infancy and continuing throughout the lifespan as a result of sickled red blood cells (Ballas, 2011; Ballas et al., 2012). Acute, recurrent, and unrelenting pain is often joined by other affective disorders that affect pain chronicity, and some patients with SCD have depression and/or sleep disturbances that may affect pain levels and quality of life (Ballas et al., 2012; Vichinsky, 2014). According to Treadwell, Barreda, Kaur and Gildengorin (2015), patients with SCD have a higher incidence of depression and anxiety compared to those in the general population, and these psychiatric conditions may develop as a result of unmanaged acute or chronic pain (Ballas et al., 2012).

The purpose of this quality improvement project is to improve the process of evaluation and treatment of depression and sleep disturbance in patients admitted with vaso-occlusive crisis. The five phases of the Stetler Model were used to guide the process of translating existing research regarding the impact of depression and sleep impairment on pain and quality of life, in patients presenting with acute sickle cell pain crisis, into evidence-based practice for this quality improvement project. An interdisciplinary sickle cell team created the Guideline for the Evaluation and Treatment of Depression and Sleep Impairment in Sickle Cell Disease, to guide the evaluation and treatment of depression and sleep impairment, and evaluate their impact on pain levels and quality of life. The sickle cell team initiated implementation of the guideline in August, 2016 as standard of care.

Patients are evaluated using four reliable and validated tools, that were incorporated in the guideline, appropriate for use in the assessment of depression, sleep impairment, pain and quality of life in patients with sickle cell disease. These tools include The Patient Health Questionnaire (PHQ-9), The Pittsburgh Sleep Quality Index (PSQI), The Quality of Life Scale (QOLS) and the Numerical Rating Pain Scale (NRS) and Simple Descriptive Pain Scale (SDPS). Patients are initially assessed, then reassessed each time the patient is admitted for sickle cell pain crisis, regardless of the results of the initial evaluation, and treatments are offered, if appropriate, based on the guideline. A chart review will be conducted with patient informed consent to collect data on initial and follow-up evaluations, as well as any treatment provided.

Descriptive statistics will include mean, standard deviation and frequencies of depression, sleep impairment, pain and QOL. Pearson correlations and t-tests will be performed to examine the linear relationships between pain, depression, sleep and QOL scores. A random-effects time series regression model using a numbered patient identifier as a panel variable will be used to account for within-person correlation. A p value of less than 0.05 will be considered statistically significant. It is anticipated that outcome data collection and analysis will be completed by April 1, 2017.

The goal of this quality improvement project is to improve overall pain levels and quality of life for patients with SCD through efficient and effective evaluation and treatment for depression and sleep impairment. Persons living with SCD are at risk for many complications associated with both the acute and chronic effects of sickling red blood cells. Close attention to the physiological and biochemical aspects of the disease, as well as, the psychological aspects associated with it, is important in order to prevent increased morbidity and mortality in this vulnerable population.

Palliative care advanced practice nurses (APNs) provide support and symptom management to patients with life-limiting and serious illnesses, including patients with SCD, as a means of improving quality of life. This project has significance for APNs in both palliative care and specialty SCD/Hematology care as a means to translate existing research into evidence-based practice; as well as provide an efficient and effective means to evaluate and treat depression and sleep impairment and their impact on pain and quality of life.