A multidisciplinary plan implemented at Yale New Haven Children’s Hospital was able to cut by more than half the number of days young sickle cell disease (SCD) patients were hospitalized for a vaso-occlusive crisis and lower their readmission rates, a study reports.
The program included pain action plans tailored to each child and psycho-education programs with likely benefits both to a patient’s well-being and in terms of overall hospital costs.
These findings were described in the study “Improving Care for Sickle Cell Pain Crisis Using a Multidisciplinary Approach,” published in the journal Pediatrics.
Hospitalizations due to vaso-occlusive crises (VOCs) are an issue for SCD patients, affecting school attendance, causing emotional distress, and reducing quality of life. They also add to the financial burden on health care systems.
Building upon documented approaches, researchers at Yale School of Medicine Pediatrics Department created a multidisciplinary program for improving care of VOC-associated pain and to reduce the number and length of admissions due to a crisis.
This program was used for five years, from October 2011 to September 2016, at Yale New Haven Children’s Hospital to manage 122 young patients (up to 21 years old; mean age 10.65) admitted for a VOC.
The multidisciplinary team included specialists in pediatric hematology, child psychology, child psychiatry, adolescent medicine, pain medicine, pediatric emergency medicine, nursing, social work, child life, and quality improvement.
Interventions included individualized home pain action plans, emergency department and inpatient order sets, an inpatient daily schedule and/or sleep hygiene, psycho-education programs and a biofeedback-relaxation assisted program.
Patients with a high number of admissions or at-risk for them (defined as four or more hospital admissions per year) received specific interventions, including an individualized SCD plan and mental health services.
The five-year program lowered hospital days spent by patients by 61%, from 59.6 days each month in its the first year to 23.2 days per month in the program’s final year.
Patients also stayed for shorter periods in the hospital — an average stay of 4.78 days was reduced to 3.84 days.
Among those with frequent admissions (four or more per month), average days in hospital each month dropped from 35.4 to 15.5 days.
The approach was also effective in reducing rehospitalization for a crisis, as judged by a drop in 30-day readmission rates from 33.9% to 19.4%.
Direct hospital costs savings amounted to more than $555,000 in the final year of the project.
“This highly reproducible and sustainable quality-improvement project resulted in a significant reduction in hospital days and improved the care and quality of life of a vulnerable patient population,” the researchers wrote.
“Standardizing care was important, but expanding nonpharmacological strategies contributed significantly to the project’s success,” they added.
Taking special care with pediatric patients who have frequent admission or are prone to them was also highlighted as a reason for this plan’s effectiveness.
“The majority of the high-use patients were on chronic transfusion or hydroxyurea (68%) in the preintervention period, but studies reveal that only [about] 50% of patients are adherent as measured by prescription refills,” the researchers wrote. “More frequent clinic visits to optimize health care (reinforcing hydroxyurea use and emphasizing home pain management) was imperative.”
Providing at-risk patients with a mental health provider was also seen as important, as many young people with long stays or frequent readmissions also show signs of mental distress, like depression and anxiety.