A Clinical Pathway Reduces Admissions for Vaso-Occlusive Pain in Sickle Cell Disease

Vaso-occlusive pain, a primary feature of sickle cell disease (SCD), leads to high acute care utilization, including frequent hospital admission. Though limited by a paucity of high quality evidence, guideline recommendations for the inpatient management of vaso-occlusive pain include rapid and continual pain assessment, early and individualized pain control, and intravenous fluid resuscitation (Yawn et. al. JAMA). However, research suggests that inpatient vaso-occlusive pain management varies significantly within institutions (Co et. al. Jt Comm J Qual Saf). Clinical pathways, which are a mechanism for increasing evidence-based management within an institution to standardize and improve quality of care, have been shown to reduce variation in vaso-occlusive pain management (Morrisey et. al. Pediatr Blood Cancer). We developed and implemented a clinical pathway for the management of vaso-occlusive pain using evidence-based interventions and expert consensus guidelines and hypothesized that it would improve clinical outcomes.

The pathway was implemented as an electronic orderset and providers were educated on its use, which was voluntary. A retrospective chart review was then performed of adult patients admitted to Tulane Hospital for vaso-occlusive pain during one year prior to and following pathway implementation (344 total admissions, 112 total patients). Outcome measures were hospital length of stay (LOS), rate of 30-day readmission, median number of hospitalizations over one year prior to and after pathway implementation, and incidence of acute chest syndrome. Use of patient-controlled analgesia (PCA) and intravenous (IV) promethazine were used as surrogate measures of pathway utilization. Data were summarized in terms of medians (IRQ) for continuous outcomes (analyzed with the Wilcoxon Rank Sum Test) and percentages for categorical variables (analyzed with the Pearson's Chi-Squared Test).

Following pathway implementation, we observed a statistically significant decrease in median number of admissions per patient (2 vs. 1, p=0.0027), an increase in PCA use (3.6% vs. 87.3%, p<0.0001), and a decrease in IV promethazine use (78% vs. 36%, p<0.0001). We observed trends toward decreased 30-day readmission (26% vs 20%, p=0.6105) and increased acute chest syndrome incidence (12% vs 18%, p=0.157), but these trends were not statistically significant. No effect was found on hospital LOS.

Increased PCA use and decreased IV promethazine use suggest high pathway utilization among providers. We suspect the decrease in median admissions occurred due to improved discharge planning, primarily arranging close followup, given that lack of an outpatient provider is a known risk factor for hospital admission for vaso-occlusive pain (Brodsky Am J Med). Despite the reduction in median admissions, the observed decrease in readmission rates was not statistically significant, possibly due to insufficient study power. A nonsignificant change in readmission rates may also suggest that additional interventions need to be developed and evaluated to address socioeconomic barriers to outpatient healthcare access, such as financial insecurity and missed appointments, which have also been identified as modifiable risk factors for readmission (Cronin et. al. Hematology). The lack of an effect on hospital LOS may be due to the confounding variable of pain episode severity, which is difficult to control for given the absence of a biomarker for vaso-occlusive disease severity. Thus, we suggest 30-day readmission and total hospital days be used as primary outcome measures in future studies.

By increasing evidence-based and expert consensus management of vaso-occlusive pain, clinical pathways may decrease hospital admissions for SCD patients. More research is needed to evaluate interventions to mitigate socioeconomic risk factors for readmission, which may then be incorporated into future clinical pathways to reduce readmission rates.