Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises

Abstract

Painful crisis episodes are poorly treated in sickle cell anemia, both in timeliness and appropriateness of care. Delayed treatment in Emergency Departments, unrelieved pain, frequent admissions, and prolonged hospitalizations are common. We established a Day Hospital (DH) to determine if an alternative care delivery system could improve pain relief and reduce unnecessary hospital admissions for patients with uncomplicated painful crises. Trained DH staff delivered prompt titration for pain relief based on each patient's analgesic history and qualitative and quantitative assessments. Response to therapy and comorbidities commanded disposition. During the first 5 years of DH operation there were 2554 visits; 60% of the patients had severe pain. During an average visit of 4.5 hours, 84% of the patients were titrated to relief; 90% had pain relief within 2 to 4 hours. Overall, 81% of the patients were discharged home (70% initially and 90% to 94% in the last 3 years). During the first 5 years of the DH, there were 2612 emergency department (ED) visits that averaged 13 hours each. The combined ED and DH admissions during this time represented a 40% decrease in the baseline ED admission rate of 92%, (1 year pre-DH). Patients with uncomplicated painful crisis were admitted 5 times less often from the DH (8.3%) than from the ED (42.7%). The length of stay (LOS) for inpatients followed by the DH staff decreased by 1.5 days, while the LOS for patients followed by non-DH staff remained unchanged. Reduction of admissions and LOS represented a savings of approximately $1.7 million. We conclude that a dedicated facility provides the kingpin for effective and rapid painful crisis management, reduces hospitalizations, and facilitates integration of the approach into other areas of care.