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Blood, Vol. 95 No. 4 (February 15), 2000:
pp. 1130-1136
PLENARY PAPER
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.
(Blood. 2000;95:1130-1136)
Painful crisis is an unpredictable, recurrent, and
poorly treated manifestation of sickle cell disease.1-14
There have been many advances in both pain management and clinical
understanding of the disease, and some patients are benefiting from
these advances.5-7,15 However, the basic
principles of pain management are not employed by many sickle cell
experts; the clinical features of the disease are not well understood
by many pain specialists; and physicians and nurses in general commonly
lack sufficient knowledge of either pain management or the disease.
Devastating consequences of these inadequacies can begin as early as
infancy and span a lifetime.1,2,14
In a national clinical course study of sickle cell disease, the acute
painful episode was the event most frequently recorded. A direct
correlation was reported between pain frequency
(greater than 3 events per year) and early death in
patients older than 20 years,14 and the use of opioids
("narcotization") has been speculated as a possible
cause.2 It is well recognized that suboptimal pain
treatment increases morbidity and possibly contributes to
mortality.16-20 While hydroxyurea reduces the frequency of
painful crises,21 the inability to treat the
underlying disease during painful crises remains a
problem.4,22 Nonetheless, the effective treatment of
pain during painful crises should be enhanced through the timely use of
available measures.22-24
Timely care can be severely compromised in busy Emergency
Departments.25,26 While some departments have been
successful with pain treatment,27 in many facilities,
patients spend hours awaiting treatment, and hours or days awaiting
disposition.28 Violating the principle of treating the pain
early can adversely affect and prolong pain.16-18,23,29
For the above reasons, we established a Day Hospital (DH) in the Bronx
Comprehensive Sickle Cell Center (BCSCC) at the Montefiore Medical
Center as a demonstration project. We sought to decrease the
load of the emergency department (ED) and to study the value of a dedicated facility with knowledgeable staff applying
principle-based individualized care. Reported here are the results of
the first 5 years of experience with this dedicated facility.
Description of the facility
Description of patients
Assessment and treatment protocol
1. Assess pain. Treatment is assessment driven. We establish whether the pain is typical or atypical vis-à-vis previous episodes. Pain intensity (overall and at specific sites), pain relief, mood, and sedation are evaluated by employing categorical scales of the Crisis Pain Assessment Form and Visual Analog Scales of the Memorial Pain Assessment Card,30 initially, or the Montefiore modification, a visual numerical scale of the same dimensions, with figure drawings to record the sites of pain. The Brief Pain Inventory Short Form, which also measures the impact of pain on affect and physical functions, is administered before and after the course of treatment.31,32 2. Select drug and loading doses. Drug selection is based upon the patient's prior history and current assessment. Recording a history establishes the standard drug and dosage required to treat the patient's painful crises, resulting side effects, medications the patient takes at home, and any medication that was taken since the onset of pain. If the patient takes opioids chronically, we assume that the patient is tolerant to the medication, and a different opioid or a higher dose of the same drug is used. 3. Titrate medication to relief. On a scale of 0-4 (0 = none, 1 = little, 2 = moderate, 3 = good, and 4 = complete relief), we define relief as a score of 2 or greater. The effect of therapy is determined in 30-minute intervals after the loading dose. Titration is continued to the highest relief achievable (scores 2-4). 4. Use by the clock dosing to maintain relief. Within 2 hours of titration, maintenance dosing and dosing intervals are determined based upon the dosing required during titration and the duration of relief. 5. Adjust rescue dosing for breakthrough pain. Approximately 1/4 to 1/2 of the maintenance dose is administered for pain that occurs between the scheduled doses. If frequent rescue doses are required, the maintenance dose is adjusted upward or the dosing interval is decreased. 6. Combine drugs to enhance the efficacy/toxicity ratio. Anti-inflammatory agents, antihistamines, and other adjuvant therapies are used in combination with opioids.17,23 7. Adjust drugs for tolerance. If, after pain control is achieved, the patient reports that the medication does not relieve pain for as long a period as previously, dose intervals are shortened. If decreased effectiveness is reported, doses are increased or changed to 1/2 the equianalgesic dose of another opioid, and then titration to relief, maintenance, and rescue are repeated. 8. Evaluate, record, and treat adverse events. Occurrence of nausea, vomiting, pruritus, respiratory depression, and sedation are recorded and treated when indicated. For sedation, the visual numerical scale (0 = wide awake and 10 = asleep) is used, and methylphenidate is employed to reverse or lessen sedation.33 9. Adjust method and route of drug delivery. For example, patient controlled analgesia22,34,35 is indicated if pain is inadequately controlled with bolus titration or if frequent dosing is required for relief maintenance. 10. Identify and treat precipitating factors. Precipitating and propagating events, such as dehydration, acidosis, hypoxia, infection, and stress, also need to be treated.1,3,4-8 Due to hyposthenuria, most patients experiencing painful crises are variably dehydrated. If dehydration is not treated sufficiently with oral hydration, 5% dextrose and 1/2 normal saline, alternating with 5% dextrose and 1/4 normal saline, is given. An alkali is indicated for documented metabolic acidosis, and oxygen is given for documented hypoxia over steady state.36-38 A low mood score after pain is relieved or bizarre graphic rendition of pain indicates a high possibility of psychological stress.30,39-41 The patient is questioned further, basic stress reduction techniques are employed, and referrals are made for follow-up visits. 11. Make dispositions based upon response to therapy and the presence or absence of comorbidities. After patients are treated in the DH, they are discharged home, transferred to the ED, or hospitalized. If pain is controlled and can be managed at home, small prescriptions of a graded analgesic regimen, based on severity of the acute event, are prescribed for patients at discharge, and an appointment for prompt follow-up is made.3,17,18,41 Patients are referred to their primary health care providers for health maintenance and routine home care. If pain is not significantly diminished, if parenteral therapy is required to maintain relief, or if significant comorbidities are present, then the patient is hospitalized. If an inpatient bed is not available or if the DH is closing for the day, the patient is transferred to the ED to continue treatment. Comparison of DH and ED length of stay and dispositions Using the DH database and the hospital's information systems, we compared the DH visits and dispositions of painful crises with those at the ED. The ED admission rate in the year prior to the opening of the DH was taken as baseline. The ED also treats the majority of patients presenting with comorbidities as well as patients with uncomplicated pain. To adjust for this, we compared DH visits only with the portion of the ED population that is comparable to the uncomplicated painful crisis population which constitutes the majority of the patients seen by the DH. Patients admitted from each unit without comorbidities, at admission and during the hospital course, were identified from inpatient discharge data. Those patients who were admitted with only unrelieved pain were combined with patients who were discharged home from the ED or the DH in order to identify the population of patients with uncomplicated pain for each unit. Admission rates for uncomplicated pain were then compared.Inpatient length of stay From the hospital admission and discharge database, the LOS for adult painful crisis patients without comorbidities (who were followed by DH physicians with house staff assistance) was compared with the LOS for patients followed by physicians unassociated with the DH.Statistical analysis and estimation of cost savings Descriptive statistics were employed to evaluate pain intensity, pain relief, and hospitalization rate (SAS statistical package). Student's t test was used to determine significance of relief and time to relief of high (frequent visits) and low (infrequent visits) users of the DH.
There were 2554 visits to the DH (Table 1) over the 5-year
period. Of these visits, 2257 were walk-in patients, and 297 patients were transferred from the ED (Figure 1).
During years 1 and 2, 76% of visits were walk-in patients. Walk-in
visits increased to 94% for years 3-5. As shown in Table
2, 22% of the patients accounted for 67%
of total DH visits.
Assessment and treatment Patients reported moderate pain in 40% of the DH visits and severe pain in 60% of the visits. On a scale of 0-3, as described previously, the overall mean pain score was 2.7 (SD = 0.7), and the median pain score was 3.0. Detailed results of pain assessment in the DH will be presented elsewhere. Patients were treated within 20 minutes of arrival. Since opioids were selected based on prior analgesic history, initially drug usage included meperidine (Demerol, 90%), morphine (4%), hydromorphone (Dilaudid, 3%) and levorphanol (Levo-Dromoran, 3%). Opioid usage was modified over time (Figure 2), and by the fifth year, usage included meperidine (63%), hydromorphone (33%), morphine (2%), and levorphanol (2%). Combination therapy was used during 75% of the visits. Opioids were used in combination with antihistamines (72%), nonsteroidal anti-inflammatory drugs (NSAID, 17%), and both antihistamines and NSAID (11%). In the third year of the study, ketorolac was introduced to the treatment regimen in 20% of the visits, and it was given to patients who historically were poor responders or who achieved less than good pain relief during the course of therapy.
Dose titration to relief and adverse effects Over the 5-year period, 84% of patients were titrated with medication to pain relief, and 40% of these patients had relief within 1 hour (Figure 3). Those patients with unrelieved pain (16%) were frequent-pain patients who experienced more than 5 visits and more than 2 hospitalizations per year. The overall mean relief score on a scale of 0-4 was 2.5. For frequent-pain patients, the mean relief score was 2.20 (SD = 0.4), whereas for infrequent-pain patients, the mean relief score was 3.1 (SD = 0.7); this difference was statistically significant (P < .0001). The overall mean time to relief was 2.5 hours. For frequent-pain patients, the mean time to relief was 3.4 hours (SD = 1.2), whereas for infrequent-pain patients, the mean time to relief was 1.7 hours (SD = 0.7); this difference was statistically significant (P < .0001). Some frequent-pain patients consistently reported pain relief only at the end of the visit (during the last assessment).
Disposition On average, 80.5% of DH visits resulted in the patient being discharged home; 8% of the visits were admitted to the hospital, and 11.5% were transferred to the ED. The percentage of walk-in DH patients discharged home increased from 70% in the first 2 years to 90%-94% in the last 3 years (Figure 1).Length of stay and dispositions in the DH and ED During the 5-year study, there were 2259 walk-in visits to the DH and 2401 direct walk-in visits to the ED (Figure 4). In the ED, 25% of patients seeking care accounted for 70% of ED visits (more than 6 visits per year). During these 5 years, 91% of the ED visits were by patients who also had visits to the DH.
Hospital admission rate During the 5-year study, an average of 51% of the ED visits (70% in the first year) and 8% of the DH visits were admitted to the hospital. A baseline assessment of ED dispositions during the year prior to establishment of the DH revealed an admission rate of 92% (Figure 4). Overall, there was a 40% reduction in hospital admission rate compared to the baseline rate. Dispositions according to frequency of visits show that the DH was more successful in discharging patients home, particularly in the high-user category (Figure 5).
Prompt revisits The possibility of recidivism (DH patients discharged home who promptly sought medical care in the ED or our facility) was examined in the first and fifth years of the study. Within 3 days of discharge from the DH, 9.5% of the discharges resulted in a revisit to either facility. All patients involved were frequent-pain patients (17.8% of patients accounted for 82% of these revisits). Of these revisits, 21% were admitted to the hospital.Impact on length of hospitalization Whether patients were admitted through the DH or ED, LOS for adult patients with painful crises without comorbidities (and who were followed by DH physicians, with the assistance of the house staff) was reduced from 9.3 days in the first year to an average of 7.3 days in the fifth year (average 7.8 days per year over the 5-year period). The LOS for patients followed by private physicians who were not connected with the DH remained unchanged.Economic impact of the DH Day hospital costs. In the 5 years reported, the DH spent $468,917 and billed $403,861, which would lead to an assessment of the DH, at least initially, as a money-losing operation. Nevertheless, the presence of the DH generated savings for the institution by reducing the hospitalization rate of patients with outlier days and by actually decreasing the LOS of inpatients, as described below. Hospital admission rate. The amount of savings due to reduction in hospitalizations was calculated using a DRG of 4.3. During the first year of the study, the baseline LOS was 9.3 days, and for inpatients followed by DH personnel, this figure was reduced on average to 7.8 days for the total 5 years. We conservatively estimated that with these patients, 7 days of hospitalization left the hospital without a deficit. Calculating the 1.5 day outlier balance as a loss per admission for 700 saved admissions, and using $1200 as the average daily hospitalization cost for a medical/surgical bed, we accrued an estimated savings of $1,200,000 compared with a situation in which all patients went to the ED. Length of hospitalization stay. Inpatient admissions followed by DH personnel had a shorter admission stay than those same patients followed by non-DH personnel. This resulted in further savings of $450,000.00 (250 admissions × 1.5 days × $1200/d).
Our experience in the DH demonstrates that most painful crises can be managed successfully and that hopelessness in the pain treatment of these patients, including those with frequent pain, is unwarranted. After a slow start, pain was ultimately controlled in 90% of the patients, a rate similar to other pain states and a more rapid control than generally achieved in sickle cell patients.35 Changes in treatment practices Flexibility in the choice of drugs. The choice of a drug was based on prior analgesic history and current assessment. Opioids are not inherently more or less efficacious when used to treat a group of patients, but they are highly influenced by pharmacokinetic and pharmacogenetic determinants of opioid response in individuals.49 Hence, treatment has to be individualized. Furthermore, any ineffective opioid administered chronically to an individual is potentially injurious.5051 Therapy modification included a reduction in meperidine usage (adjustment for tolerance), although none of the patients had seizures from meperidine usage in the DH. Adjuvant therapies, including antihistamines, NSAID, and introduction of parenteral ketorolac in year 3, were found useful. Overcoming undertreatment. Undertreatment of pain in medicine is well recognized,16,21,52 in part as a consequence of bias to opioid usage, especially in minority and frequent-pain patients. Furthermore, it is possible that if pain control is delayed, the undertreatment becomes a propagating factor. The sequelae of untreated or undertreated pain include hypoxia, dehydration, acidosis, and stress,29,52 all well-known precipitating factors for painful crises. By addressing the great variability of patients' responses to therapy and promptly assessing and titrating the patients' treatments, we decreased the magnitude, duration, and time to relief of pain. More than 80% of patients were titrated to relief during the DH visit, and this time period was less than 4 hours for frequent-pain patients and less than 2 hours for nonfrequent-pain patients. The increase in relief and pain reduction in the DH is at least partially attributed to an increase in walk-in visits (from 80% to 99%) and a corresponding decrease in transfers from the ED, resulting in greater initiation of therapy in the DH. Reduction in meperidine usage and the addition of parenteral ketorolac coincided with a decrease in the rate of hospitalizations. Decrease in the rate of hospitalizations Since the DH opened, there has been a 40% reduction in hospital admission rate compared with the dispositions in the ED when it was the only site for treatment. Overall, there was a 5- to 7-fold decrease in the rate of hospital admissions by the DH compared with admissions by the ED. A decreased hospitalization rate was observed among patients with uncomplicated painful crises who were transferred from the ED to the DH, although this decrease was not of the magnitude of the decrease for direct walk-in visits. Although the ED saw more patients with comorbidities (30% ED compared with 20% DH), when the rate of admissions of painful crises without comorbidities were compared, the rate of admission remained 5-fold less in the DH.Partial impact on frequent-pain patients While we were able to reduce the hospitalization rate of frequent-pain patients, they remain a problem and require a supplemental approach.53 In the DH, 22% of patients accounted for 67% of the visits, and this proportion was similar in the ED.Impact on inpatient service The average length of hospital stay decreased during the 5-year study among adult patients followed by the DH staff, but the length of hospital stay remained stationary in patients followed by staff not associated with the DH.Hospital administration response to DH impact on hospital economics The DH-associated savings were generated by decreasing the time in the outpatient facility, the rate of hospitalization, and the inpatient length of hospital stay.54,55 The hospital administration response to the DH performance has been encouraging. After years of uninterrupted federal funding of this demonstration project, an economical analysis resulted in the complete funding of an expanded DH operation by the hospital. In our new facilities, we now have 6 beds (rather than 3), expanded personnel, and expanded hours of operation (from one to two 8-hour shifts). This is the best proof of the economical soundness of this operation. Other institutions have also supported successful dedicated facilities for sickle cell anemia patients.56,57The pivotal value of the DH acute pain unit A major dilemma and current focus in pain management is to find ways to actually change practices.58-60 Despite the climate for change created by research advances, evidence-based clinical practice guidelines, quality improvement, and educational activities, traditional patterns of professional practices have persisted as the most formidable barrier to relieving pain.61 Our results buttress the concept of alternative care delivery systems, such as the dedicated DH, as a pivotal element for removing such barriers. Not only is it a centralized unit that treats pain effectively, it also represents a resource for patients, families, and health care professionals; serves to rapidly incorporate research advances; and has a clear impact on in-house care because patients who are hospitalized are already in an appropriate track of treatment.
The authors wish to acknowledge the nurses, hematology fellows, and staff of the Sickle Cell Center; the medical house staff; and members of the ED, all of whom contributed significantly to the success of this effort. Institutional support is gratefully acknowledged.
Submitted January 28, 1999; accepted October 1, 1999.
Supported in part by grant HL38655 from the National Institutes of Health, Bethesda, MD.
Reprints: Lennette J. Benjamin, Bronx Comprehensive Sickle Cell Center, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467.
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734.
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  L. R. Solomon Treatment and prevention of pain due to vaso-occlusive crises in adults with sickle cell disease: an educational void Blood, February 1, 2008; 111(3): 997 - 1003. [Abstract] [Full Text] [PDF]
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 A. H. Adewoye, V. Nolan, L. McMahon, Q. Ma, and M. H. Steinberg Effectiveness of a dedicated day hospital for management of acute sickle cell pain Haematologica, June 1, 2007; 92(6): 854 - 854. [Abstract] [Full Text] [PDF]
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 M. J. Booker, K. L. Blethyn, C. J. Wright, and S. M. Greenfield Pain management in sickle cell disease Chronic Illness, March 1, 2006; 2(1): 39 - 50. [Abstract] [PDF]
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R. Lottenberg and K. L. Hassell An Evidence-Based Approach to the Treatment of Adults with Sickle Cell Disease Hematology, January 1, 2005; 2005(1): 58 - 65. [Abstract] [Full Text] [PDF]
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 J. P. Needleman, L. J. Benjamin, J. A. Sykes, and T. K. Aldrich Breathing Patterns During Vaso-occlusive Crisis of Sickle Cell Disease* Chest, July 1, 2002; 122(1): 43 - 46. [Abstract] [Full Text] [PDF]
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 R. L. Nagel The Challenge of Painful Crisis in Sickle Cell Disease JAMA, November 7, 2001; 286(17): 2152 - 2153. [Full Text] [PDF]
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Abstract
Introduction
