Background:
We are a large academic hospitalist group in a tertiary care center with a mixed urban/suburban catchment area. Despite representing only 4% of our total discharges, patients with sickle cell disease (SCD) account for 17% of our total excess days and the majority of our 30‐day readmissions. Acute painful crises are the most common reason for admission. Inconsistent care, psychosocial issues and poor outpatient follow‐up contribute adversely to these metrics.
Purpose:
To create a sickle cell task force comprised of hospitalists, pediatric and adult hematologists, nursing leadership and education, care coordinators and outpatient providers to develop a coordinated and evidence‐based approach to care.
Description:
Through research and consultation with other institutions, the task force created a multidisciplinary care team and developed best‐practice guidelines to standardize care for sickle cell patients. A core group of 8 hospitalists (out of 28) was identified to assume care of these patients. Schedules were modified to ensure that at least one of these physicians was available at any given time. The core group was certified by Anesthesiology to administer PCA (patient‐controlled analgesia). Pain control was limited to PCA or pills. Bolus administration was discouraged to minimize the risks of overdose and to avoid the “high” which can contribute to addiction and long length of stay (LOS). An electronic, evidence‐based sickle cell order set was developed. PCA and SCD training was provided to 2 units and patients with SCD are cohorted to these floors. Each patient is evaluated by hematology. Case management provides home services if indicated and information about support groups. An outpatient internal medicine physician visits the patients while admitted and provides outpatient follow‐up within 5 days of discharge. This has the dual benefit of only needing to write a 5‐day prescription of narcotics and the comfort of knowing that the patient will have close follow‐up. At their outpatient visit, patients are given an ID card that indicates their medication doses and baseline hemoglobin so that individualized care can be provided at subsequent emergency department (ED) visits and admissions. Patients with multiple 30‐day readmissions are reviewed with Quality Control and potential solutions are explored. An ED diversion plan has been created and we are currently working with the ED to provide earlier and appropriately dosed analgesia to improve pain control and when possible, avoid unnecessary admissions. A patient satisfaction tool is in progress.
Conclusions:
Since the task force’s inception in early 2013, the LOS for patients with SCD has decreased by more than a day and excess days have decreased by 40%. 30‐day readmissions have decreased by 11% and are trending towards a greater than 60% reduction. By forming a disease‐specific care team, we are able to standardize and thereby improve the quality of care we provide to patients with SCD with appreciable results.