Comparing Emergency Department and Infusion Clinic Outcomes Among Individuals with Sickle Cell Disease Seeking Care for Vaso-Occlusive Crises

Background: Sickle Cell disease (SCD) is a rare genetic disorder of the blood that results in red blood cells sickling and occluding blood vessels. Vaso-occlusive crises (VOCs) are the most common clinical manifestation of SCD which are characterized by excruciating levels of pain. The Emergency Department (ED) has long been the standard location for SCD patients to seek treatment for these acute pain crises. However, the ESCAPED trial demonstrated that Infusion Care Clinics (ICs) are a beneficial alternative to the ED model of care by providing higher quality patient care (e.g., reduced time to first dose) leading to reduced hospitalizations, and higher patient satisfaction. This PCORI funded study is evaluating the implementation of infusion care to treat VOCs in SCD patients at 9 clinical sites. Models of infusion care vary widely across the 9 sites and include either a shared clinic or a designated SCD clinic, both within and outside of the hospital setting. To further evaluate the real word effectiveness of IC care, we compare the time to first dose of analgesic pain medications and patient disposition between patient seen in the IC or ED.

Method: Data from acute visits to the IC and ED for VOCs was abstracted from the electronic medical record at the 9 clinical sites. Sites were instructed to abstract data from all IC visits and from a randomly selected day a week at the ED over two years. Patient disposition was defined as the location patient was discharged after care and was recorded after the patient visit. Time to first dose was calculated by subtracting the check-in time from the first analgesic pain medication administration time. Disposition rates and average time of first dose was compared between IC and ED across all 9 sites using a chi square and T test.

Findings: Over the course of data collection, 3121 visit dispositions were documented, with 2545 visits to the IC and 576 visits to the ED across all 9 sites. Of the 2545 visits to the IC, 31 (1.2%) visits led to hospital admission (range across all 9 sites: 0-3.84%), whereas 229 of the 576 (39.75%) visits to the ED resulted in hospital admission (range across 6 sites: 1.3-86.9; X-squared = 24.71, df =1, p-value<0.001) and IC: X-squared = 2329.4, df = 1, p-value <0.001. The average time to first dose for ICs was 38.67±35.60 minutes, whereas the ED time to first dose had an average time of 104.79±95.11 ( p-value< 0.001 )and a confidence interval (CI) of (58.68, 73.55).

Discussion: These findings demonstrate the real-world effectiveness of infusion care compared to the ED for VOC in individuals with SCD. Individuals seen in the infusion center had significantly lower times to first dose and were less likely to be admitted to the hospital when compared to individuals seen in the ED. This data provides further support for varying models of infusion care in different settings. There is a continued need to identify best practices for implementing and expanding access for infusion care in individuals with SCD.