Creating a Hospitalist Managed Comprehensive Sickle Cell Anemia Program

Background:

In 2007 our Department QI Hospital Medicine was responsible lor the care QI more than 90% QI admissions for adults wilh sickle cell anemia (SCA), the majority of which were for sickle cell crisis. The total SCA population was about 100 patients, only 70 of whom were admitted in 2007. However, distributions of both LOS and admissions/patient were heavily left skewed, with long tails, indicating that a small cadre of patients was admitted frequently and stayed longer. IV posh narcotics were used for pain, resulting in poor control, outbursts by patients, and stress on nursing staff. A disproportionately large volume of patient complaints were made To Ihe institutional ombudsman's office.

Purpose:

The purpose of This project is to develop a comprehensive SCA program that will improve The inpatient care for sickle cell crisis and provide better coordination of inpatient and outpatient care for the SCA population.

Description:

We collaborated wilh a successful local SCA program to identify critical success factors that could translate to our institution. Those factors were: (1) highly standardized pain control regimen with patient‐controlled anesthesia pumps (PCAs); (2) a small group of providers in‐ and outpatient; (3) close coordination of care between clinic, ED, and hospital; and (4) frequent involvement by social work and case management. Our first step was to hire an inpatient nurse coordinator to manage patient expectations concerning PCA pumps, ensure physician compliance with the pain protocol, and coordinate outpatient care. Standardized admission orders were developed to start PCA pumps, which are managed via protocol thereafter. During the first posbmplementation admission, baseline PCA settings are established. In subsequent admissions, patients spend Ihe first 24 hours al the baseline setting, and narcotic dose is titrated down by 25% per day. Inpatient care is assigned to a single nonteaching hospitalist team, and patients are admitted to a single hospital floor. Patients are rounded on daily by a multidisciplinary team of a dedicated SCA social worker, the SCA nurse coordinator, and the hospitalist. A list of SCA patients is maintained in the electronic medical record, and patients admitted to the ED or clinical decision unit are seen by the inpatient team. Two primary care providers (PCPs) with an interest in SCA were recruited, and patients without PCPs have appointments made within 7 days of discharge. The program is funded by $80,000 from a local foundation matched by $80,000 from internal funds.

Conclusions:

The SCA nurse coordinator started in July 2009 and since August 1, 90% of patients have been admitted to the designated hospital floor and managed by the SCA hospitalist team, 95% have been managed with PCA pumps, and 100% have a follow‐up PCP appointment arranged at discharge Twenty‐four of the 40 unique patients admitted since January 2009 now have established baseline PCA settings. There has not been a single complaint to The ombudsman's office since the program started.

Author Disclosure:

R. Patrick, none; N, Dalpiaz, none; B. Coe, none; 5. Manda. none; A. Clay, none.