An Innovative Approach to the Management of Sickle Cell Disease at Johns Hopkins Aramco Health in The Kingdom of Saudi Arabia.

Background: Patients with SCD have frequent hospitalizations due to repeated vascular occlusion resulting in multiple organ damage, acute on chronic pain, fatigue, and frequent infections2. Sickle cell pain crisis challenges patients and health professionals in countries like Saudi Arabia where the disease is common and use of narcotic analgesics is strictly controlled3. Sickle cell disease is the number one reason for Emergency Department (ED) visits at JHAH where a hospital medicine program has been in operation since October, 2010. This hospitalist service manages 50% of total hospital admissions and 90% of the admissions to medicine. SCD makes up 10% of the ED’s 46,000 yearly visits. While JHAH has a hematology-oncology service, a limited number of beds and hematologists, meant that the hospitalists managed the majority of the patients with SCD. There weren’t many good options for outpatient sickle cell disease management and this resulted in prolonged length of stay (LOS) for admitted patients.

Purpose: Limited inpatient beds and specialists (hematologists) necessitated an innovative approach in the management of patients with SCD at JHAH. A Sickle cell infusion center, staffed by a hospitalists, was established with the primary goal of reducing inpatient admissions for SCD. A Sickle cell infusion center, with this staffing model, is the first of its kind in Saudi Arabia.

Description: In April, 2017, JHAH opened the Sickle cell unit that is physically located in the emergency department. It has 6 beds and is open 24 hours a day and 7 days a week. It is staffed by a dedicated hospitalist during the day and by ED providers overnight. Nursing is provided by the ED staff and a hematologist is consulted as needed. This staffing model has provided continuity of care for the patients who visit the ED frequently. Individualized care plans for high utilizers have been developed by a multi-disciplinary team consisting of the sickle cell hospitalist provider, a hematologist, ED charge nurse, social work, and a pain management nurse. The program is able to provide not just pain management, but also longitudinal care in that patients who come back to the ED are frequently taken care of by the same provider. The average occupancy on the unit is 3-6 patients and the average length of stay (LOS) is 6-8 hours. From April 2016 through March 2017 (before the intervention), there were 1285 patients presenting to the ED with SCD. From April 2017 through September 2017 (after the intervention), there were 608 patients presenting with SCD. When comparing the periods before and after the initiation of the intervention, the admission rate dropped from 30.56 (±6.19) to 21.39 (±4.94) (P<0.0001). Time to first dose of pain medications has been reduced from 90 minutes to 69.9 minutes (P<0.0001). This program has helped patients avoid hospitalizations; therefore, patients can go back to work sooner. Patients previously struggled to get outpatient appointments, but now they get quicker follow-up and there is better coordination of care. Coverage by the same hospitalist allows the provider to dig deeper into the psychosocial issues behind the crisis.

Conclusions: The hospitalist group leads the charge in clinical care and quality improvement at JHAH. The innovative partnership with hematology, nursing, and the ED, which resulted in the establishment of the sickle cell unit, has resulted in reduced admissions for SCD and improvement in the provision of care for this patient population.