A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers

Abstract

Introduction: A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the healthcare needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily.

Methods: We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (seven months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included patient-specific best practice advisories (BPA); an ED management protocol; and formation of a "medical home" for these patients.

Results: For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods we found the following: ED visits decreased by 16.5 visits/pt-yr (95% confidence interval [CI] [-1.32-34.2]); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI [-82.9-313.5]); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI [-1.73-10.1]); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI [-74.9-146.7]); and visits where the patient left before treatment were reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects, and no patient required admission to the intensive care unit 72 hours following discharge.

Conclusion: This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.

Figure

The sickle-cell disease super-utilizer protocol was designed to expedite analgesic administration and reduce redundant laboratory tests and imaging for patients meeting inclusion criteria. If patients are determined to be clinically stable by the provider with appropriate vital signs, the patient’s treatment plan developed by the multidisciplinary team can be implemented, thereby expediting and standardizing care. If the patient has been evaluated by laboratory examination or radiographs in the ED or clinic within five days of their current ED visit, the provider can defer work-up at that time and implement the patient’s treatment plan, serving to reduce redundant work-up and further expedite and standardize care. If a hematologic emergency is suspected, a comprehensive evaluation is warranted based on provider discretion. ED, emergency department; VOE, vaso-occlusive event.