AbstractSevere acute pain is common in sickle cell disease (SCD). Increasingly overburdened emergency departments are not the most appropriate setting in which to manage pain that requires close monitoring and careful opioid dose titration.1 We report on the benefit of treating acute pain in SCD in a day hospital (DH).
The DH, a 2-bed monitored unit, was set up in July 2002 and operates between 8 am–5 pm, 5 days a week for the evaluation and treatment of acute uncomplicated SCD pain. Admission to the DH is controlled by a nurse practitioner (NP) who independently manages the patients. A hematologist is available for consultation. Patients are evaluated for pain control every half hour and IV opioids titrated to pain relief accordingly in a stepwise fashion. Records of SCD patients with the following ICD9 codes of 282.42, 282.62, 282.64 and 282.69 (corresponding to uncomplicated acute painful episodes) who attended the outpatient SCD clinic or the emergency department (ED) were reviewed for the period between January 2000 and December 2003. Admissions and discharges related to ED and DH visits were calculated from the records. Our study was approved by the Institutional Review Board at our institution. A baseline admission rate of 58.65% was calculated for ED visits prior to the establishment of the DH. Inpatient admission rates from the ED and DH admission were 57.6% and 5% respectively (Table1). Mean hospital cost for all patients seen in the DH vs ED was $1,609 vs $2,689 (p value <0.0001). The mean length of stay (LOS) was 5.7 days vs 3.6 days (p<0.02) in the DH vs ED.
The management of SCD is well described.2–6 Wright et al.7 and Benjamin and co-workers in a large metropolitan hospital have reported on the establishment of a DH. They showed a reduction in ED use, hospital admissions, hospital LOS and a reduction in total hospital health-care costs in their patient populations (a $1.7 million dollar saving with the establishment of a DH over a five-year period).8 Rapid alleviation of pain should be a prime goal in the management of pain in patients with SCD because the frequency of painful episodes is associated with earlier death.9
While 94% of our subjects reported pain relief after 4 hours of continuous pain management and IV hydration, 6% of patients were admitted to the hospital for unresolved pain. Patients were likely to be admitted into hospital if pain control could not be achieved within 4 hours of presentation to the DH. We Most healthcare facilities use the same for diagnosis and procedures. Therefore, cost represents an easy comparison between healthcare facilities.10 Overall, for all patients, the hospital cost was much lower in the DH compared to the ED $2,689.07 vs $1,609.52 (p-value <0.0001). This is a saving of $1,080 for each patient seen in the DH instead of the ED. Over a number of years several millions of dollars are saved. Approximately 95% of subjects who used the DH for acute painful episode were discharged home, compared to 43% in the ED (Table 1). This could be due to the low patient to nurse ratio in the DH and the availability of dedicated medical personnel who quickly identified and alleviated the patient’s pain so hospital admission was not required. This would be impossible in the ED because of the complexity of cases and patient load. Gender was not shown to affect hospitalization rates. Our data took into account outcomes of ED visits during periods when the DH was not open. This showed more subjects were discharged home reflecting an increase in discharge rate above the baseline in the ED (patients were too few for statistical analysis). Since patients were admitted to a dedicated SCD service this may explain why no difference was observed in LOS. This is in contrast to the Benjamin study where patients were admitted to either a SCD or general medicine service. The calculated cost does not include the additional direct and indirect cost of maintaining the ED or the DH with regards to the number of FTE (much higher in the ED vs DH). To summarize, when patients with SCD form a clinically significant number of all hospital admissions, a DH is a useful approach to manage their uncomplicated acute pain.
we thank Mark Yoder, NP, for contributing to data acquisition for this project
- Disclosures: this paper was presented at the 29th Annual meeting of the National sickle cell disease program, April 8–12, 2006.
- Funding: supported in part by the NHLBI, 1U54 HL 0708819.
- Shapiro BS, Dinges DF, Orne EC, Bauer N, Reilly LB, Whitehouse WG. Home management of sickle cell-related pain in children and adolescents: natural history and impact on school attendance. Pain. 1995; 61:139-44. PubMedhttps://doi.org/10.1016/0304-3959(94)00164-AGoogle Scholar
- Steinberg MH. Predicting clinical severity in sickle cell anaemia. Br J Haematol. 2005; 129:465-81. PubMedhttps://doi.org/10.1111/j.1365-2141.2005.05411.xGoogle Scholar
- Buchanan GR, Debaun MR, Quinn CT, Steinberg MH. Sickle cell disease. Hematology (Am Soc Hematol Educ Program). 2004;35-47. Google Scholar
- Bonds DR. Three decades of innovation in the management of sickle cell disease: the road to understanding the sickle cell disease clinical phenotype. Blood Reviews. 2005; 19:99-110. PubMedhttps://doi.org/10.1016/j.blre.2004.04.002Google Scholar
- Steinberg MH, Barton F, Castro O, Pegelow CH, Ballas SK, Kutlar A. Effect of hydroxyurea on mortality and morbidity in adult sickle cell anemia: risks and benefits up to 9 years of treatment. JAMA. 2003; 289:1645-51. PubMedhttps://doi.org/10.1001/jama.289.13.1645Google Scholar
- Moore RD, Charache S, Terrin ML, Barton FB, Ballas SK. Cost-effectiveness of hydroxyurea in sickle cell anemia. Investigators of the Multicenter Study of Hydroxyurea in Sickle Cell Anemia. Am J Hematol. 2000; 64:26-31. PubMedhttps://doi.org/10.1002/(SICI)1096-8652(200005)64:1<26::AID-AJH5>3.0.CO;2-FGoogle Scholar
- Wright J, Bareford D, Wright C, Augustine G, Olley K, Musamadi L. Day case management of sickle pain: 3 years experience in a UK sickle cell unit. Br J Haematol. 2004; 126:878-80. PubMedhttps://doi.org/10.1111/j.1365-2141.2004.05123.xGoogle Scholar
- Benjamin LJ, Swinson GI, Nagel RL. Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises. Blood. 2000; 95:1130-6. PubMedGoogle Scholar
- Platt OS, Thorington BD, Brambilla DJ, Milner PF, Rosse WF, Vichinsky E. Pain in sickle cell disease. Rates and risk factors. N Engl J Med. 1991; 325:11-6. PubMedhttps://doi.org/10.1056/NEJM199107043250103Google Scholar
- Federal R. Centers for Medicare and Medicaid Services (CMS), HHS. Federal Register. 2006; 71:47869-48351. PubMedGoogle Scholar