Implementation of Individualized Pain Management in Vaso-occlusive Pain Crisis

Olivia West MSN, AG-ACNP-BC

Sickle cell disease (SCD) is the most common genetic disease in the United States affecting 1 in 500 African Americans.¹ Unfortunately, a major challenge for patients with SCD is lack of access to specialty hematology services. Dedicated health care providers with SCD expertise are scarce, especially in low-income and rural settings.² Patients with SCD often utilize emergency services because of a lack of specialty care in the outpatient setting which in turn leads to increased hospital admissions and readmissions all of which contribute to high treatment costs.²

In the United States alone, there are over 230,000 hospital admissions related to SCD annually, 95% of which are related to vaso-occlusive pain crisis (VOC).³ The estimated annual economic cost for VOC related hospital admissions is greater than 2.4 billion dollars.³ The average hospital stay for patients with VOC is 9 to 11 days.3 In addition, patients with SCD seeking pain relief are often stigmatized and measures to manage the opioid epidemic have further limited access to necessary pain relief.²

Within a major academic medical center in the Southeast, inpatient hematology/oncology providers noted a trend within the SCD population presenting for treatment. These patients were often significantly underdosed, leading to extended hospital lengths of stay as well as readmissions. In response, our multidisciplinary team implemented individualized pain protocols to provide specialized hematology care and expedited pain management; subsequently decreasing hospital length of stay and improving patient quality of life.

QUALITY IMPROVEMENT INITATIVE

Our institution implemented several interventions to improve care for patients with SCD admitted for VOC. We established a team of hematology nurse practitioners to care for patients presenting with uncomplicated VOC. This allowed for specialty care as well as continuity of care for patients who experience frequent VOC.

In conjunction with a specialized SCD attending physician and outpatient nurse practitioner, individualized initial pain protocols were developed for each patient seen in the outpatient setting. Individualized pain protocols were initiated upon patient presentation to the emergency department and/or upon admission to provide expedited, appropriate pain management. To ensure continuity of care between the inpatient and outpatient settings, inpatient and outpatient sickle cell teams met weekly to discuss current inpatients pain management protocols as well as follow-up appointments and disease management treatment plans.

In addition to hematology nurse practitioner led care, these patients were placed on hematology/oncology inpatient units allowing for specialized nursing care. Nursing staff’s specialty training allowed for first line nursing interventions such as heat therapy and frequent pain reassessments to be prioritized to assist with pain management. These interventions allowed for expedited, aggressive pain regimens for our patients with sickle cell and in return have decreased hospital length of stay.

RESULTS

Hospital length of stay for patients with VOC across the medical institution was evaluated over the past 5 years with a focus on effect of the hematology nurse practitioner inpatient teams.²

Average cost of care for this population was determined by our institution to be $1300 per day. After implementation of the above interventions within the inpatient hematology nurse practitioner team, average length of stay was 3.9 to 6.6 days compared with other teams within the medical institution averaging up to 14 days length of stay. Further, these averages were less than half of national average VOC length of stay of 9 to 11 days.³

Implementation of these interventions resulted in an average health care cost savings of $3900 per patient or $808,080 per year. In addition, quality of life for patients with VOC was improved as pain was treated efficiently and effectively allowing for a shorter hospitalization.

CONCLUSION

The practice protocols established by our specialty hematology nurse practitioners allowed for improved access to care and expedited pain management. As a result, patients suffering from VOC experienced improved pain control and reduced length of stay.

Utilization of specialty nurse practitioner driven teams and use of individualized pain protocols for patients admitted with VOC in other institutions could significantly improve quality of life for patients with SCD, decrease hospital length of stay, as well as health care costs associated with inpatient admissions.

Future directives should include utilizing nurse practitioner specialty practices to provide urgent pain management in the outpatient setting to mitigate inpatient admissions.³

References

Lovett PB, Sule HP, Lopez BL. Sickle cell disease in the emergency department. Hematol Oncol Clin North Am. 2017;31(6):1061-1079. doi:10.1016/j.hoc.2017.08.009

Lee L, Smith-Whitley K, Banks S, Puckrein G. Reducing health care Disparities in sickle cell disease: a review. Public Health Rep. 2019;134(6):599-607. doi:10.1177/0033354919881438

Darbari DS, Sheehan VA, Ballas SK. The vaso-occlusive pain crisis in sickle cell disease: definition, pathophysiology, and management. Eur J Haematol. 2020;105(3):237-246. doi:10.1111/ejh.13430