Collaborative Management of the Adult with Sickle Cell Disease

Abstract

Problem

Our hospital has seen an increase in lengths of stay and costs over the past three years for adult patients with sickle cell disease (SCD). Tarrant County has one county run adult SCD clinic. Patients report long waits and poor care.

Evidence

Many adults with SCD have difficulty finding physicians to provide consistent care, increasing visits to emergency departments for pain management. Current Best Practice Guidelines are available to direct the management of patients experiencing pain and/or sickle cell crisis in hospital and emergency department settings.

Strategy

A Clinical Nurse Specialist (CNS) led a multidisciplinary task force looking at national trends and best practices. The task force met from August to September 2007 to develop the care model, clinical pathway, physician order sets, and an equianalgesic pain table. The CNS initiated in-patient rounding for SCD patients in September. Physician order sets and clinical pathways were finalized, approved and implemented in November.

Practice Change

An evidence-based protocol was implemented that included a 5-day clinical pathway, physician’s orders for emergency and in-patient management, CNS rounding on all SCD patients, case conferences, and outpatient referral processes.

Evaluation

Variable direct costs decreased by 30% and length of stay decreased by 23% from September to December. Nurses reported increased competence in providing care to SCD patients.

Results

Rounding and case management by the CNS, including interdisciplinary care conferences, has improved communication between all disciplines. Education and communication continues for physicians, patients and staff.

Recommendations

A brochure is being developed to explain the guidelines to patients and family members in the emergency department. A citywide collaborative process has begun including all area hospitals, the SCD clinic and the Sickle Cell Disease Association. The goals are to improve care for SCD patients and increase utilization of SCD care resources other than emergency departments and inpatient care.

Bibliography

• Institute for Clinical Systems Improvement (2006). Assessment and management of acute pain. Retrieved August 8, 2007, from National Guidelines Clearinghouse http://www.guidelines.gov.
• Larsen, L., Neverett, S., Larsen, R. (2001). Clinical Nurse Specialist as Facilitator of Interdisciplinary Collaborative Program for Adult Sickle Cell Population. Clinical Nurse Specialist, 15(1) pp15–22.
• Mandell.E. (2000). Care Coordination for Patients with Sickle Cell Disease. Joint Center for Sickle Cell and Thalassemic Disorders Brigham and Women’s Hospital. Retrieved February 1, 2007, from http://sickle.bwh.harvard.edu/coordination.html.
• NIH Publication No 02-2117 (2002). The Sickle Cell Information Center. National Institute of Health, National Heart, Lung, and Blood Institute (4th ed). Retrieved 08/08/2007, from http://www.scinfo.org.
• Okam.M. (2007). Development of a Comprehensive Care Program for Patients with Sickle Cell Disease. Information Center for Sickle Cell and Thallassemic Disorders.
• Sickle Cell Society (2004). Information for Health Professionals.