Pain Management in Patients with Sickle Cell Disease through an Inpatient Sickle Cell Disease Consult Service

Introduction:

For patients living with Sickle Cell Disease (SCD), interactions with the healthcare system are both frequent and prolonged, which further exacerbates the need for providers experienced in treating this population. Despite this need, few comprehensive SCD centers exist. To address this disparity, we have developed an inpatient SCD consult service to provide a consistent treatment framework for this patient population. This consists primarily of a multidisciplinary team to optimize pain management and initiate disease-modifying therapies such as Hydroxyurea.

After implementing this consult service at the University of Chicago Medical Center in 2022, objective metrics were collected to evaluate the impact of the service. This project sought to characterize the changes in healthcare utilization after program initiation.

Methods:

After identifying key stakeholders and specific care gaps in the delivery of high-quality care to patients with SCD in prior studies, we implemented a consult service comprised of advanced practice providers in partnership with a combined medicine-pediatrics physician. This team evaluated each patient and guided pain management in the form of individualized pain plans (IPP) to be followed during admissions. These plans were also communicated to the primary team while also providing extensive, SCD-focused education. For patients without an IPP on admission, one was created using both pharmacologic and non-pharmacologic therapies. Patients were also monitored for the development of additional SCD-related complications and provided with guidance regarding the initiation of Hydroxyurea.

To monitor the progress of these interventions, we conducted an electronic medical record (EMR) review of patients who interacted with our SCD consult service for the first two years after project implementation (7/17/2022 to 6/13/2023 and 7/17/2023 to 6/13/2024). First, we analyzed the data to identify changes in patient interaction with the consult service. Next, we detailed the pharmacologic pain management strategies utilized during admission. Finally, an analysis using descriptive statistics was conducted to identify changes in healthcare utilization including length of stay (LOS) and number of hospitalizations. This study was conducted under quality improvement and was not overseen by an Institutional Review Board.

Results:

During the first- and second-years following implementation, there were a total of 154 and 178 patients admitted with SCD-related complications respectively. Within this cohort, there were a total of 488 admissions during the first year of implementation and 567 during the second year. The number of new consult requests to the SCD Consult Team increased by 115% from 214 to 462. The percentage of SCD admissions with a consult order placed increased from 44% to 81%.

When evaluating healthcare utilization metrics, the average length of stay decreased from 6.9 days after the first year of implementation to 6.6 days after the second year, representing a 4.4% decrease in LOS. The average LOS before implementation of this program was 7.8 days resulting in a 17.9% decrease after two years.

Prior to the implementation of the consult service, 82 patients had an IPP at the time of admission. Over the first and second years of the service, IPP increased to 122 (a 49% increase year over year) and 143 (a 17% increase year over year), respectively. Over the 2-year period, the IPPs have increased by 61 patients or 74%. Currently, 80% of admitted patients carry an IPP to manage their pain.

Conclusion:

Despite the challenges in delivering healthcare to patients living with SCD, creative approaches involving multidisciplinary teams may provide a tenable solution. By utilizing a small group of providers dedicated to improving outcomes for patients with SCD, this program has provided a framework for delivering standardized care. Creating IPPs and having a consult service creates institutional memory for patient care, which can result in improvements in pain management and ultimately a lower LOS. Nevertheless, implementation of a program such as this also has limitations including difficulty securing consistent staffing and limited funding. In the future, the development and expansion of similar programs may provide a novel solution to the growing challenge of delivering healthcare to patients with SCD.