Blood, Vol. 95 No. 4 (February 15), 2000:
pp. 1130-1136
PLENARY PAPER
Sickle cell anemia day hospital: an approach for the management
of uncomplicated painful crises
Lennette J. Benjamin,
Gwendolyn I. Swinson, and
Ronald L. Nagel
From the Department of Medicine, Division of Hematology, Bronx
Comprehensive Sickle Cell Center, Montefiore Medical Center of the
Albert Einstein College of Medicine, Bronx, NY.
Painful crisis episodes are poorly treated in sickle cell anemia,
both in timeliness and appropriateness of care. Delayed treatment in
Emergency Departments, unrelieved pain, frequent admissions, and
prolonged hospitalizations are common. We established a Day Hospital
(DH) to determine if an alternative care delivery system could improve
pain relief and reduce unnecessary hospital admissions for patients
with uncomplicated painful crises. Trained DH staff delivered prompt
titration for pain relief based on each patient's analgesic history
and qualitative and quantitative assessments. Response to therapy and
comorbidities commanded disposition. During the first 5 years of DH
operation there were 2554 visits; 60% of the patients had severe pain.
During an average visit of 4.5 hours, 84% of the patients were
titrated to relief; 90% had pain relief within 2 to 4 hours. Overall,
81% of the patients were discharged home (70% initially and 90% to
94% in the last 3 years). During the first 5 years of the DH, there
were 2612 emergency department (ED) visits that averaged 13 hours each.
The combined ED and DH admissions during this time represented a 40%
decrease in the baseline ED admission rate of 92%, (1 year pre-DH).
Patients with uncomplicated painful crisis were admitted 5 times less
often from the DH (8.3%) than from the ED (42.7%). The length of stay (LOS) for inpatients followed by the DH staff decreased by 1.5 days,
while the LOS for patients followed by non-DH staff remained unchanged.
Reduction of admissions and LOS represented a savings of approximately
$1.7 million. We conclude that a dedicated facility provides the
kingpin for effective and rapid painful crisis management, reduces
hospitalizations, and facilitates integration of the approach into
other areas of care.
