Background: Vaso-occlusive acute pain crises are the leading cause for hospitalization in adult sickle cell patients. For our academic hospitalist group at a quaternary care center in New York, acute pain crises in 2017 accounted for 65 admissions, with an average length of stay (LOS) of 10.28 days, and readmission index (observed-over-expected ) of 1.10. During this time, there was no standardized protocol in the treatment of pain crises as it relates to medication management and supportive care; there were wide variations in our group’s treatment plans, resulting in frequent readmissions and protracted hospitalizations.
Purpose: Our hospitalist division sought to create a specialized team of hospitalists to be trained to care for sickle cell patients, in a collaborative approach with palliative care, nursing leadership, and a dedicated outpatient internal medicine primary care doctor who cares specifically for this population. By creating this robust care team, we aimed to reduce the frequency of rehospitalizations, and improve patient outcomes on the inpatient service.
Description: A core group of 11 hospitalists were chosen to assume care for patients admitted to the service with sickle cell acute pain crisis. This core group was trained by palliative care physicians to use Patient Controlled Analgesia (PCA) pumps for inpatient pain management, in lieu of IV push administration. Pain control options during hospitalization for sickle cell patients were limited to PCA pumps or oral analgesics. A standardized order set within our electronic medical record was utilized by the admitting teams as well. Nurses on our medical floors were trained to operate PCA pumps, and these patients were preferentially assigned to one of three units within the hospital that had this specialized training. Case management and social work evaluations were completed on all patients prior to discharge. The task force hospitalists communicated closely with the outpatient primary care doctor for the sickle cell group, and vital information about the patient including previous opioid dosing history, baseline hemoglobin, pertinent medical history, course of hospitalization, discharge plan, and follow up care were shared between the two. Post-discharge appointments with this primary care doctor were expedited for patients so that they could be seen as an outpatient within 3-5 days.
Conclusions: In the six months since the task force was implemented, the LOS for patients with pain crises decreased by 4.48 days (43% from baseline), 30-day readmission index decreased from 1.10 to 0.28, and excess days per case were reduced by 4.6 days. The effect on patient satisfaction is unclear due to small sample size.The standardization of care and the implementation of a collaborative interdisciplinary approach helped to improve the quality of the care we provided to our sickle cell patients, and ultimately decrease the utilization of inpatient admissions for this diagnosis.