Study Summary: Reducing Admissions Among Children With Sickle Cell Disease Through Implementation of an Individualized Pain Plan

Study Highlights

• Vaso-occlusive crisis is the most common reason for hospital admission among pediatric patients with sickle cell disease.
• Strategies that integrate individualization and standardization of care may reduce the burden of vaso-occlusive crisis in pediatric patients with sickle cell disease.
• Utilization of individualized pain plans has been shown to reduce admission rates among pediatric patients with sickle cell disease who present to the emergency department with vaso-occlusive crisis.

Background

Sickle cell disease (SCD) is an inherited red blood cell disorder.¹ Based on data from 2001 to 2005, the average lifetime cost of care has been estimated at nearly $500,000 per patient, 80.5% of which is associated with inpatient hospitalizations.¹ Vaso-occlusive crisis (VOC) is a painful complication of SCD and the leading cause of hospitalization in pediatric patients with SCD. Severe VOC pain may require an emergency department (ED) visit or hospital admission when oral analgesics are insufficient to control pain.¹

Various strategies to reduce the burden of VOC have been evaluated, including standardizing and/or individualizing care.¹ Use of algorithmic or individualized strategies is increasingly advocated; however, supporting data are limited.¹ The results of one study showed that implementation of individualized pain plans (IPPs) reduced admission rates; however, the intervention involved using a dedicated ED sickle cell nurse.¹ Integrating a sickle cell practitioner in the ED may not always be feasible; thus, investigators at the Children’s Hospital of Richmond (CHoR) sought to develop a standardized approach to creating IPPs that is effective in reducing VOC admission rates without requiring a dedicated ED sickle cell practitioner.¹ The primary goal of this study was a 20% reduction in VOC admission rates within 6 months of initiating IPPs.¹

Study Background and Design

A multidisciplinary quality improvement team at CHoR developed a template that provided a standardized approach to creating IPPs for pediatric patients with SCD.¹ The IPP template included algorithms for VOC treatment in the ED, inpatient, and outpatient settings based upon patient-specific factors. The patient’s recent VOC ED encounters were evaluated to determine opiate dosing. Prior ED medication dosages that prevented admission were noted in the IPP. If the ED encounter led to admission, a higher starting opiate dose was considered. Standard dosing was used for patients with no VOC ED encounters in the prior year. The template also included a section for patient-specific details (eg, medication of choice, opiates to avoid, and supportive care considerations).¹

Investigators initially identified and created IPPs for 80 pediatric patients with the highest ED utilization in the prior year.¹ Thereafter, IPPs were created as needed for patients presenting to the ED or clinic for VOC who required hospital admission. This prospective study evaluated IPP implementation in the ED setting and included pediatric patients with SCD (aged ≤18 years) with 1 or more prior VOC encounter who presented to the ED with VOC.¹

The primary outcome was hospital admission rate. Other key measures included length of stay (LOS), rates of readmission and 72-hour return to the ED, and direct hospital costs.¹

Results

A total of 307 patient encounters involving VOC were included in this study. Data from 599 pre-IPP implementation VOC encounters were collected for baseline comparison.¹

The overall admission rate post-IPP implementation (41%) was significantly lower compared with the year prior to implementation (57%; P = .016) and the 5-year pre-implementation average (51%; P = .046).¹ The postimplementation admission rate for patients with an IPP was lower than patients without an IPP; however, this difference was not significant (39% vs 52%, respectively).¹ An analysis of data from 25 children with the highest pre-implementation ED utilization showed a significant reduction in admission rate from 64% to 52% (P = .0431). Nearly two-thirds of the 25 children (n = 16; 64%) had a decrease in admissions per ED visit.¹

With regard to the relationship between time to second opiate dose and admission rate, the likelihood of admission for pain crisis increased as the time to second dose increased. Patients discharged from the ED had a significantly shorter time to second dose than those who required admission (66 minutes vs 103 minutes, respectively; P = .008). The admission rate was significantly lower in patients who received a second dose less than 45 minutes after the first dose (P = .001).¹ Notably, there were no incidences of respiratory depression, somnolence, or other safety events observed among patients who received a second dose less than an hour after the first dose. There was no association between existence of an IPP and time to second dose; however, it was noted that the study was likely not powered to assess this relationship given the high IPP adoption rate.¹

With regard to average LOS and rates of readmission and 72-hour return to the ED, no changes were seen postimplementation compared with the year prior to implementation.¹

Average hospital costs and patient charges after IPP implementation were lower compared with the year prior to implementation.¹ It was estimated that 49 admissions were prevented during the 12 months postimplementation, which saved an estimated $240,020 in direct hospital costs. For the 126 admissions during the 12-month postimplementation period, there was a total estimated cost savings of $85,156. Thus, implementation of IPPs saved approximately $325,176 in direct hospital costs per year.¹

Conclusion

The results of this study demonstrated that strategies integrating individualization and standardization of care may reduce the burden of VOC in pediatric patients with SCD. IPP implementation led to a reduction in VOC admission and reduced costs without increasing ED utilization. The authors noted that the 41% postimplementation admission rate was considerably lower than rates reported by prior studies of VOC in children (50% to 78%).¹ The study also uncovered a correlation between shorter time to receiving a second opiate dose and decreased likelihood of admission.¹ Given these promising results, further studies are warranted to assess the impact of the individual components of this approach and its use in outpatient settings.¹

Reference

1. Schefft MR, Swaffar C, Newlin J, Noda C, Sisler I. A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department. Pediatr Blood Cancer. 2018;65(10):e27274. doi: 10.1002/pbc.27274.