Abstract
Background: In Ontario, Canada, quality standards have been developed to promote the timely and effective management of patients with sickle cell disease (SCD) presenting to acute care settings; however, the uptake of recommended care metrics into routine clinical practice remains inconsistent. Most initiatives have focused on establishing protocols in tertiary care academic centers; however, many Canadian patients seek care at community-based institutions where SCD care pathways may be lacking. Our study aims to assess the quality of care provided to patients with SCD presenting to community emergency departments (EDs), using benchmark metrics outlined in current clinical guidelines from Ontario Health and the American Society of Hematology (ASH).
Methods: We conducted a retrospective chart review of adult patients with SCD seen between January 2017 and December 2024 at four community EDs in southwestern Ontario, serving a catchment of approximately 230,000 people. Emergency and inpatient metrics were collected and stored in a REDCap database. Descriptive statistics were used to summarize demographic and clinical characteristics of ED visits and hospital admissions. Multivariable Cox, linear, negative binomial, and logistic regression models were used to examine associations with key outcomes, and statistical significance was defined as p < 0.05.
Results: Between 2017 and 2024, a total of 160 ED SCD-related visits were recorded across four community hospitals in southwestern Ontario, involving 47 unique adult patients. The median age at presentation was 24.1 years [interquartile range (IQR) 20.4-30.9], and 55.7% of visits (n=89) involved male patients. Female patients had significantly more ED visits per individual, with an 83% higher visit rate than males [incidence rate ratio (IRR):1.83, p = 0.024]. Vaso-occlusive episodes (VOEs) were the most common reason for ED visit (n=125; 78.1%), followed by acute chest syndrome (ACS) (n=17; 10.6%), hepatobiliary complications (n=5; 3.1%), and priapism (n=4; 2.5%).
Median length of ED stay was 11.2 hours (IQR 7.4-17.6) and median time to first analgesia from ED triage registration was 2.7 hours (IQR 1.6-5.5). Only four patients (2.5%) presenting with VOE received analgesia within the recommended 30-minute timeframe. Increasing age was independently associated with shorter time to analgesia, with each additional year reducing wait time by 6.5 minutes (p = 0.033). The type of analgesia used in the ED included opioids in 139 (86.9%) visits, NSAIDs in 45 (28.1%), and acetaminophen in 42 (26.3%). Most visits (83; 51.8%) involved opioid use alone.
The majority (111; 69.4%) of visits required hospital admission. Median inpatient length of stay was 4.2 days (IQR 2.3-7.1). VOE was the most common reason for admission (n = 80, 72.1%). Forty-four inpatient admissions (40.4%) involved an RBC transfusion. Pharmacologic venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin was prescribed in 74.5% of admissions. Consulting services during hospitalization included Hematology (31; 27.9%), Acute Pain Service (14; 12.6%), Surgical (13; 11.7%), Internal Medicine (8; 7.2%), and ICU (7; 6.3%). ACS developed in 27 admitted patients (24.3%); incentive spirometry was documented in only 8 (7.6%) admissions. Ten (9.1%) patients required transfer to a higher acuity setting. Male sex was associated with a significantly increased likelihood of developing ACS (p= 0.030) and being transferred to a higher acuity setting (p= 0.008).
Conclusions: In our study cohort, most patients with SCD presenting to community hospitals in southwestern Ontario did not receive care aligned with provincial quality standards or the ASH clinical practice guidelines. Gaps were identified in the timely administration of analgesia for VOE, use of multimodal analgesia, pharmacologic thromboprophylaxis, and incentive spirometry to reduce complications such as ACS. These findings demonstrate the need to enhance SCD resources in regional hospitals. We aim to use these data to advocate for system-level improvements to support guideline-based care for patients with SCD outside tertiary centers. Future studies will compare care metrics from community hospitals in our region to those of our academic partner to better understand disparities. With growing immigration in our region, building person-centered, evidence-based SCD pathways is essential to address persistent health inequities faced by individuals living with SCD.
