Memorial Regional Hospital

Sickle Cell Day Hospital – A Solution That Works

Sickle cell anemia, an inherited condition occurring most frequently in African Americans and Hispanic Americans, is a serious and painful disease that often leads to frequent inpatient admissions and emergency department (ED) visits. Appropriate, comprehensive management of sickle cell patients in the outpatient setting can reduce morbidity and health care utilization, but few such programs exist. Memorial Regional Hospital, however, has created a replicable program with its Sickle Cell Day Hospital outpatient clinic.

A painful condition, leading to frequent hospitalization and ED visits
People with sickle cell anemia frequently experience acute crises in which irregular (sickle-shaped) red blood cells block small blood vessels, thereby impeding blood and oxygen flow and causing severe pain. These episodes frequently lead to the need for inpatient and/or ED care. The largest study to date on use of acute services by recently discharged sickle cell anemia patients found that 40 percent required readmission or ED care for pain treatment within 30 days of discharge.

Unrealized potential of outpatient management
Uncomplicated acute pain episodes and chronic pain in sickle cell patients can often be managed successfully on an outpatient basis with patient-tailored pain management and assessment. Yet, most health systems do not offer this type of program.

Memorial Regional Hospital’s Sickle Cell Day Hospital (SCDH) implemented in 2003 provides an alternative to inpatient care for patients with sickle cell anemia, with the goal of appropriately managing their pain and reducing inpatient utilization. At SCDH, patients receive an initial assessment that includes a complete physical examination from a nurse practitioner and/or internist; appropriate, individualized outpatient pain management overseen by the hematologist and palliative care physician; and ongoing plan-based care management including monitoring of sickle cell anemia co-morbidities, basic primary care and psychosocial assessment. SCDH patients have lower lengths of stay and lower ED utilization than the hospital’s sickle cell anemia patients who are not treated at this facility.

How does it work?

Located within Memorial Regional Hospital, SCDH includes one large room with nine infusion chairs, a second room with a hospital bed, two patient examination rooms, and two semiprivate rooms with two infusion chairs each. Patients typically self-refer, although ED personnel, physicians and managed care companies can also refer to the program. Approximately 90 percent of the hospital’s sickle cell anemia outpatient visits occur at SCDH.

A patient care assistant greets any new patient who arrives for acute pain management. The assistant takes the patient's vital signs; measures height, weight and other clinical parameters; and administers a quality-of-life questionnaire. Patients then meet with a general internist or nurse practitioner for a complete history and physical examination. This clinician decides whether the patient can safely be treated at the day hospital or should be admitted to the main hospital.

Targeted pain management
Patients deemed appropriate for day hospital management receive pain management medication according to internally developed protocols. The clinician contacts the center’s hematologist, who orders a loading dose of intravenous opioid pain medication, and the anesthesiologist orders a patient-controlled analgesia pump. (In contrast, patients in the inpatient setting typically receive an intravenous dose of opioids every 2 to 3 hours as needed for pain.) During medication infusion, a nurse monitors the patient’s vital signs and pain levels every 30 minutes during the first hour, and then every hour thereafter (usually for a total of roughly 5 hours). The physician prescribes or reviews the patient’s outpatient pain medication and encourages the patient to adhere to the medication regimen.

Ongoing disease management
SCDH patients also receive ongoing disease management and psychosocial assessment based on a customized care plan. Information about the patient’s condition is entered into the health system’s sickle cell anemia registry, which interfaces with the electronic clinical and administrative databases. This process enables providers to develop a comprehensive care plan and monitor patients for disease-related complications, such as eye disease, cardiac function, sleep disorders and iron overload due to blood transfusions. Patients return monthly for medication monitoring and have follow-up visits every six months. Ongoing management includes:

• Primary care: For the many patients who do not have primary care providers, the nurse practitioner assesses primary care needs, including vaccinations.
• Psychosocial assessment: A social worker conducts a one-hour interview with each patient every six months, and creates a psychosocial profile to assess patients’ social needs and monitor depression. The social worker makes referrals to a psychologist, psychiatrist or community services as necessary.
• Weekly palliative care symptom management clinic: A palliative care physician holds a weekly clinic for patients with chronic pain. Patients attend the clinic for pain assessment, medication prescriptions, and adjustment of short- and long-acting pain medications and anti-inflammatory medications.
• Complementary and alternative therapies: The hematologist may prescribe nutritional supplements. The day hospital also offers aromatherapy, acupuncture and Reiki therapy.

Results

Sickle Cell Day Hospital patients have lower hospital length of stays and fewer ED visits than do similar patients not treated by the program. In addition, day hospital visits have grown substantially over time, which developers view as a mark of the program's success.

• Lower length of stay (LOS): Inpatient LOS among sickle cell anemia patients averaged 7 to 9 days. The average LOS for day hospital patients who require inpatient care is 2 days less than that of similar patients treated at Memorial but not managed at the day hospital.
• Fewer ED visits: Day hospital patients have 33 percent fewer ED visits than do Memorial sickle cell patients not treated at the day hospital. In addition, 15 percent of day hospital patients had no ED visits during fiscal years 2009 and 2010. In comparison, 100 percent of hospitalized non–day hospital patients had at least one ED visit within the same timeframe. Of hospitalized non-day hospital patients, 100 percent had ED visits.
• Growth in visits: Visits to the day hospital have more than tripled in six years, from 750 during the first year of operation (fiscal year 2004) to 2,599 in fiscal year 2010. Program leaders believe this growth is a reflection of the program's success.

Adopting the replicable model
Success depends in large part on finding a physician with a passion for and interest in sickle cell anemia who will be dedicated to development of the program. This physician champion takes responsibility for securing buy-in from hospital leaders, marketing the program to patients and other potential referral sources, and monitoring clinical advances and research trials. Leaders will often support the program once they understand its potential to reduce patient morbidities and costs (through reductions in inpatient admissions and ED visits). In addition, officials suggest that outside review can confirm the quality of program services. For example, the Sickle Cell Day Hospital has invited The Joint Commission to review its services, receiving certification every year since 2004. The program was the first of its kind in the nation to receive "Disease-Specific Certification" from The Joint Commission.

Sustaining the Program
Program sustainability depends on having adequate staffing, both for administrative and clinical positions. Moreover, the physician champion makes sure the program remains up to date on best practices in sickle cell treatment, pain management, and alternative therapies.


For more information about the Sickle Cell Day Hospital at Memorial Regional Hospital, contact:
Lanetta Jordan, MD, MPH, MSPH
Director, Sickle Cell Services
Memorial Regional Hospital
954-265-4422
ljordan@mhs.net  

References/Related Articles
Sickle Cell Day Hospital – Sickle Cell Treatment Services. Memorial Regional Hospital. Available at: http://www.memorialregional.com/services/sickle-cell-treatment.  

U.S. Agency for Healthcare Research and Quality. New Study Details High Rates of Rehospitalizations and Emergency Pain Treatment of Sickle Cell Disease. Press Release. April 6, 2010. Available at: http://www.ahrq.gov/news/press/pr2010/sicklecellpr.htm.  

Benjamin LJ, Swinson GI, Nagel RL. Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises. Blood. 2000;95(4):1130-6. [PubMed]