Implementation of a Community Hospital-Based Fast Track Pathway for the Treatment of Acute Pain Episodes in Adults with Sickle Cell Disease

Background: A growing number of adult patients with sickle cell disease (SCD) receive care in a community setting and often lack access to physicians with sickle cell expertise. To address this healthcare disparity we are testing a co-management medical home model with Hematology/Oncology (H/O) and Family Medicine (FM) physicians to facilitate evidence-based acute and chronic care. An Emergency Department (ED) Observation Unit based pathway for treatment of sickle cell pain developed at an academic medical center with a Comprehensive Sickle Cell Center (CSCC) has been adopted and modified to fit the needs of a community multi-specialty hospital with an unopposed FM residency program. The hospital serves a large sickle cell population in a predominantly rural setting with the closest CSCC 180 miles away.

Methods: Pathway development was facilitated by having a formal meeting for the community hospital physicians and staff at the academic medical center and sickle cell experts providing ongoing on site consultation at the community hospital. Protocols for the community hospital were produced with input from physicians, nurses, advanced practice providers, and support services at multiple meetings. Adult patients with SCD presenting to the ED with pain are triaged at Emergency Severity Index Level 2 for evaluation by the ED physician. The ED protocol uses specific criteria to identify patients with uncomplicated pain. Patients presenting with abnormal vital signs (other than mild tachycardia), fever, pregnancy, or apparent other sickle cell-related complications are excluded. Patients qualifying for the pathway are directly admitted to the SCD unit (a hospital room with 4 infusion chairs on the H/O floor exclusively designated for care of sickle cell patients). Following intake evaluation by the nurse, a clinician is notified to evaluate the patient and provide orders for intravenous fluids and opioid patient controlled analgesia (PCA) which is administered according to hospital guidelines. PCA by the subcutaneous route is used if intravenous access is not readily available. A CBC is obtained whereas other laboratory testing and imaging studies are ordered based on clinical indications. H/O physicians and nurse practitioners cover the unit weekdays 8:00am-5:00pm and FM residents cover nights and weekends with back up by the on call H/O physician. Patients can be treated in the SCD unit up to 23 hours. For patients discharged home a follow up phone call by an H/O nurse will be placed within 3 days and an outpatient clinic appointment is scheduled to be within 7 days. Monthly quality assurance meetings are attended by H/O, FM, and ED physicians as well as nursing, pharmacy and administrative staff from the ED and H/O inpatient service to review process issues and patient outcomes. Consultation is provided by academic physicians with sickle cell expertise (H/O and ED) who attend each meeting in person or by conference call.

Results: From March 5-June 30, 2014, 67 patients accounted for 271 visits to the SCD unit. The mean time in the unit was 13.6 hours. The mean pain score on admission was 8.7/10 and reduced to 4.9 upon discharge. PCA drug, pump setting, and dosage are recorded to be used for future visits. Over the 4 months 91.1% of the patients were discharged home from the unit. Six patients accounted for 31% (84) of the visits with only 4 hospital admissions.

Conclusions: A fast track pathway for the treatment of acute sickle cell pain coordinated between ED, H/O, and FM physicians has been implemented at a community hospital using an Observation Unit based treatment program. During the entire initial experience the majority of patients have been discharged home with adequate pain relief. In the future the impact of the program will be evaluated including effect on frequency of hospitalizations, outpatient follow up, patient satisfaction, and cost effectiveness. The pathway can be adapted to other community hospital settings where sickle cell expertise is not locally available.