SummaryMemorial Regional Hospital’s Sickle Cell Day Hospital provides an alternative to inpatient care for patients with sickle cell anemia, with the goal of appropriately managing their pain and keeping them out of the hospital. Patients receive an initial assessment that includes a complete physical examination from a nurse practitioner and/or internist, and appropriate outpatient pain management overseen by a hematologist and palliative care physician. Patients also receive ongoing management based on a care plan, which includes monitoring of sickle cell anemia comorbidities, basic primary care, and psychosocial assessment. Day hospital patients have lower lengths of stay and lower emergency department utilization than the hospital’s sickle cell anemia patients who are not treated at the day hospital.Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including length of stay (LOS) and emergency department (ED) visits, along with post-implementation trends in visits to the day hospital.
Developing OrganizationsMemorial Regional Hospital
Date First Implemented2003
Race and Ethnicity > Black or African American; Hispanic/Latino-Latina; Vulnerable Populations > Racial minorities
Problem AddressedSickle 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 ED visits.1 Appropriate, comprehensive management of sickle cell patients in the outpatient setting can reduce morbidity and health care utilization, but few such programs exist.
- 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.1 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.2,3
- 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.
Description of the Innovative ActivityThe Sickle Cell Day Hospital provides an alternative to inpatient care for patients with sickle cell anemia, with the goal of managing their pain and keeping them out of the hospital. Day hospital patients receive an initial assessment that includes a complete physical examination from a nurse practitioner and/or internist, and appropriate outpatient pain management overseen by a hematologist and palliative care physician. Patients also receive ongoing management based on a care plan, which includes monitoring of sickle cell anemia comorbidities, basic primary care, and psychosocial assessment. Other services include a weekly palliative care clinic and alternative and complementary therapies. Key program elements include the following:
- Location and layout: Located within Memorial Regional Hospital, the Sickle Cell Day Hospital 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.
- Program referral: Patients typically self-refer, although ED personnel, physicians, and managed care companies can also refer patients to the program. Approximately 90 percent of the hospital’s sickle cell anemia outpatient visits occur at the day hospital.
- Initial assessment: 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 individual decides whether the patient can safely be treated at the day hospital or should be admitted to the main hospital.
- Acute pain management: Patients deemed appropriate for day hospital management receive pain management medication according to internally developed protocols. The physician or nurse practitioner contacts the center’s hematologist, who orders a loading dose of intravenous opioid pain medication, and the anesthesiologist, who orders a patient-controlled analgesia pump. (By contrast, in the inpatient setting, patients typically receive an intravenous dose of opioids every 2 to 3 hours). 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 approximately 5 hours). The physician prescribes or reviews the patient’s outpatient pain medication and encourages the patient to adhere to the medication regimen.
- Ongoing management according to care plan: Patients 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, pulmonary hypertension, obstructive sleep apnea and other sleep disorders, vitamin D deficiency, and iron overload due to blood transfusions. Patients return monthly for medication monitoring and have followup visits every 3 months. Ongoing management includes the following:
- 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 1-hour interview with each patient every 6 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 antiinflammatory medications.
- Complementary and alternative therapies: The hematologist may prescribe nutritional supplements, including L-arginine, zinc, and/or magnesium. The day hospital also offers aromatherapy, acupuncture, and Reiki therapy.
References/Related ArticlesSickle 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]
ResultsSickle Cell Day Hospital patients have lower hospital LOS 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.
Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including length of stay (LOS) and emergency department (ED) visits, along with post-implementation trends in visits to the day hospital.
- Lower LOS: 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 seen 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 time frame.
- Growth in visits: Visits to the day hospital have more than tripled in 6 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.
Context of the InnovationThe 690-bed Memorial Regional Hospital is part of Memorial Healthcare System, a large public health system in South Broward County, FL. The health system treats more than 1,000 sickle cell anemia pediatric and adult patients each year. As the director of clinical resource management, Dr. Lanetta Jordan (now the director of sickle cell services) reviewed hospital data on top diagnoses by cost, LOS, and patient volume; researched optimal strategies for managing these diagnoses; and worked with the chiefs of the clinical departments to develop protocols to be used to improve inpatient care. She found that although sickle cell anemia patient volumes remained relatively low compared with other diseases, inpatient LOS among sickle cell anemia patients averaged 7 to 9 days. This average was well above the Geometric and Arithmetic LOS for complicated (MS-DRG 811) and uncomplicated (MS-DRG 812) sickle cell diagnosis codes (3.8 days and 5.2 days, respectively, for MS-DRG 811, and 2.8 days and 3.6 days, respectively, for MS-DRG 812), with 90 percent of painful episodes being uncomplicated. She also found that the system offered few if any outpatient services for sickle cell patients. Based on these findings, Dr. Jordan felt that outcomes for sickle cell patients could be improved and costs lowered by focusing on better outpatient management of the disease.
Planning and Development ProcessSelected steps included the following:
- Background research: Dr. Jordan researched strategies to improve the outpatient management of sickle cell anemia patients. During this process, she identified literature describing a sickle cell day hospital in which uncomplicated pain episodes were successfully managed in an outpatient setting.
- Approval by hospital leaders: Dr. Jordan presented her research to the chief medical officer and suggested the implementation of an outpatient service model within the hospital setting. She also presented an analysis of the model’s potential impact on ED and hospital utilization. The chief medical officer signed off on the program and then worked with Dr. Jordan to secure hospital leadership approval for the day hospital.
- Meeting with managed care companies: Hospital representatives met with representatives of managed care companies to obtain approval to bypass the standard authorization process to provide acute pain management on an outpatient basis.
Resources Used and Skills Needed
- Staffing: Center staff include a director, a full-time-equivalent hematologist/oncologist (with duties shared by a group of five physicians who rotate weekly), an internal medicine physician, a palliative care physician, a primary care nurse practitioner, two full-time registered nurses, a patient care assistant, a social worker, a clinical research associate, an epidemiologist, and an outreach educator. The day hospital treats between 8 and 11 acute pain patients and 10 followup patients daily.
- Costs: Data on upfront development costs are not available, but these costs include the space, infusion chairs, and other equipment outlined previously. The primary ongoing costs consist of staff salary and benefits.
Funding SourcesMemorial Regional Hospital
Memorial Regional Hospital funded development of the program and pays the salaries of day hospital staff. Insurers (including Medicaid, Medicare, and private insurers/managed care organizations) generally cover day hospital services; only 3 percent of day hospital patients lack insurance.
Getting Started with This Innovation
- Identify physician champion: Success depends in large part on finding a physician with a passion for and interest in sickle cell anemia who will be dedicated to the development of the program. This physician 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.
- “Sell” leaders by emphasizing quality and cost benefits: 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).
- Invite outside review: 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 This Innovation
- Ensure proper staffing: Program sustainability depends on having adequate staffing, both for administrative and clinical positions.
- Stay current with best practices: The physician champion makes sure the program remains up to date on best practices in sickle cell treatment, pain management, and alternative therapies.
Use By Other OrganizationsOnly a handful of organizations operate comprehensive outpatient sickle cell centers, including Duke University Medical Center (Durham, NC), Montefiore Medical Center of the Albert Einstein College of Medicine (Bronx, NY) and Grady Health System (Atlanta, GA).
1 Sickle Cell Day Hospital – Sickle Cell Treatment Services. Memorial Regional Hospital. Available at: http://www.memorialregional.com/services/sickle-cell-treatment.
Broussea DC, Owens PL, Mosso AL, et al. Acute care utilization and rehospitalizations for sickle cell disease. JAMA 2010;303(13):1288-1294. [PubMed]
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Service Delivery Innovation Profile
Original publication: June 22, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 27, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.