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.

Painful crisis is an unpredictable, recurrent, and poorly treated manifestation of sickle cell disease.1-14There 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.

Patients and methods

Description of the facility

During the period covered in this report (1989-1993), the DH provided care for patients with uncomplicated painful crises. The DH, located in the 1700-square-foot BCSCC at Montefiore Medical Center, included a triage room, 3 beds, and a clinical laboratory for sample processing. The BCSCC also included an outpatient facility for health maintenance; offices for the clinical director, nurse coordinator, administrator, and education and psychosocial counselors; and a meeting/teaching area. The DH hours of operation were Monday through Friday from 9:00 am to 5:00 pm for both walk-in patients and transfer patients from the ED, who were treated in the ED while the DH was closed.

Description of patients

During the first 5 years of the DH, 144 patients sought treatment for acute pain crises of varying frequency. This represents a mean of 70 patients and more than 500 visits per year (Table1). The median age of the patients was 30 years, and 81% of the patients had homozygous sickle cell anemia. Male patients outnumbered female patients during the first 2 years of the facility operation. During the last 3 years of the study, a nearly-equal distribution of the sexes was treated, with female patients averaging 57% of the visits.

Table 1.

Demographics

Year  1  2  3  4  5  Mean  
No. of patients 66  67  63  77  70  68.6  
Male (%) 39 (59.1%)  37 (55.2%)  32 (50.8%)  40 (51.9%) 35 (50.0%)  36.6 (53.4%)  
Female (%)  27 (40.9%) 30 (44.7%)  31 (49.2%)  37 (48.1%)  35 (50.0%) 32.0 (46.6%)  
No. of Visits  358  483  622  550 541  511  
Male (%)  152 (42.5%)  257 (53.2%) 267 (43.0%)  222 (40.4%)  204 (37.7%) 220 (43.1%)  
Female (%)  206 (57.5%) 226 (46.8%)  355 (57.1%)  328 (60.0%)  337 (62.3%) 290 (56.8%)  
Age (Median years)  29.8 30.0  30.4  30.4  30.8 —  
Disease Group  
 SS 58 (87.9%)  55 (82.0%)  49 (77.8%)  60 (77.9%) 62 (88.6%)  56.8 (82.8%)  
 SC  7 (10.6%) 6 (8.9%)  8 (12.7%)  10 (13.0%)  3 (4.2%) 6.8 (9.9%)  
 Sβ + THAL  —  1 (1.4%) 2 (3.2%)  3 (3.9%)  3 (4.3%)  1.8 (2.6%) 
 SβO THAL  —  4 (6.0%)  2 (3.2%) 3 (3.9%)  1 (1.4%)  2.0 (2.9%)  
 SO ARAB 1 (1.5%)  1 (1.5%)  1 (1.6%)  1 (1.3%) 1 (1.4%)  0.8 (1.2%)  
 SD  —  — 1 (1.6%)  —  —  0.4 (0.6%) 
Ethnicity of Patients 
African-American 54 (81.8%)  55 (82.1%)  49 (77.8%)  62 (80.5%) 52 (74.3%)  54.4 (79.3%)  
Hispanic-American 12 (18.2%)  11 (16.4%)  13 (20.6%)  15 (19.5%) 17 (24.3%)  13.6 (19.8%)  
Other  0  1 (1.5%) 1 (1.6%)  0  1 (1.4%)  0.6 (0.8%)  
Ethnicity by Visits 
African-American  271 (75.7%) 350 (72.5%)  465 (74.7%)  411 (74.7%)  381 (70.2%) 375.4 (73.5%)  
Hispanic-American  87 (24.3%) 128 (26.5%)  151 (24.3%)  139 (25.3%)  159 (29.4%) 132.8 (25.9%)  
Other  0  4 (0.8%)  5 (0.8%)  1 (0.2%)  2 (0.4%) 
Year  1  2  3  4  5  Mean  
No. of patients 66  67  63  77  70  68.6  
Male (%) 39 (59.1%)  37 (55.2%)  32 (50.8%)  40 (51.9%) 35 (50.0%)  36.6 (53.4%)  
Female (%)  27 (40.9%) 30 (44.7%)  31 (49.2%)  37 (48.1%)  35 (50.0%) 32.0 (46.6%)  
No. of Visits  358  483  622  550 541  511  
Male (%)  152 (42.5%)  257 (53.2%) 267 (43.0%)  222 (40.4%)  204 (37.7%) 220 (43.1%)  
Female (%)  206 (57.5%) 226 (46.8%)  355 (57.1%)  328 (60.0%)  337 (62.3%) 290 (56.8%)  
Age (Median years)  29.8 30.0  30.4  30.4  30.8 —  
Disease Group  
 SS 58 (87.9%)  55 (82.0%)  49 (77.8%)  60 (77.9%) 62 (88.6%)  56.8 (82.8%)  
 SC  7 (10.6%) 6 (8.9%)  8 (12.7%)  10 (13.0%)  3 (4.2%) 6.8 (9.9%)  
 Sβ + THAL  —  1 (1.4%) 2 (3.2%)  3 (3.9%)  3 (4.3%)  1.8 (2.6%) 
 SβO THAL  —  4 (6.0%)  2 (3.2%) 3 (3.9%)  1 (1.4%)  2.0 (2.9%)  
 SO ARAB 1 (1.5%)  1 (1.5%)  1 (1.6%)  1 (1.3%) 1 (1.4%)  0.8 (1.2%)  
 SD  —  — 1 (1.6%)  —  —  0.4 (0.6%) 
Ethnicity of Patients 
African-American 54 (81.8%)  55 (82.1%)  49 (77.8%)  62 (80.5%) 52 (74.3%)  54.4 (79.3%)  
Hispanic-American 12 (18.2%)  11 (16.4%)  13 (20.6%)  15 (19.5%) 17 (24.3%)  13.6 (19.8%)  
Other  0  1 (1.5%) 1 (1.6%)  0  1 (1.4%)  0.6 (0.8%)  
Ethnicity by Visits 
African-American  271 (75.7%) 350 (72.5%)  465 (74.7%)  411 (74.7%)  381 (70.2%) 375.4 (73.5%)  
Hispanic-American  87 (24.3%) 128 (26.5%)  151 (24.3%)  139 (25.3%)  159 (29.4%) 132.8 (25.9%)  
Other  0  4 (0.8%)  5 (0.8%)  1 (0.2%)  2 (0.4%) 

Assessment and treatment protocol

We used the following assessment and treatment protocol in the DH. Patients were assessed by a nurse and physician prior to initiation of therapy. Assessment and the initial treatment occurred within 15 to 20 minutes of the patient's arrival at the DH. At half-hour intervals, patients completed the rapidly administered assessment instruments through a sequential combination of nurse interview and self-administered questionnaire. Treatment decisions and final dispositions were made based on the responses. The specific procedures in the DH are listed below.

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 ¼ to ½ 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 ½ 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 ½ normal saline, alternating with 5% dextrose and ¼ 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.

We also estimated the costs of operating the DH and the cost savings for reducing hospital admission rate and LOS for patients without comorbidities.42 We used $1200 as the average daily cost of a medical/surgical bed, and an average length of hospital stay was estimated at 9.3 days. A cost-reduction model was used to calculate the impact of the decreased rate of hospitalizations. The savings of decreased hospitalization costs were calculated based on a diagnosis-related group (DRG) of 4.3 days. We estimated conservatively that 7 days of hospitalization costs were covered by third-party payors and that the 1.5-day excess was a loss.

Inpatients followed by DH staff had shorter LOS hospitalizations, and these savings were also calculated by multiplying the reduction in LOS by the number of admissions and the daily cost of occupying a hospital bed.

Results

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 Table2, 22% of the patients accounted for 67% of total DH visits.

Fig. 1.

DH visit source and patient dispositions, according to visit source.

Patients presented either directly from home as walk-in visits to the DH or were transferred to the DH after an initial course of treatment in the ED (central pie chart). Dispositions are depicted according to walk-in visits (left pies) and transfers from the ED (right pies) as patients discharged home, admitted as inpatients, or transferred/returned to the ED for additional therapy if needed at closing of the DH.

Fig. 1.

DH visit source and patient dispositions, according to visit source.

Patients presented either directly from home as walk-in visits to the DH or were transferred to the DH after an initial course of treatment in the ED (central pie chart). Dispositions are depicted according to walk-in visits (left pies) and transfers from the ED (right pies) as patients discharged home, admitted as inpatients, or transferred/returned to the ED for additional therapy if needed at closing of the DH.

Table 2.

Frequency distribution of DH use: average visits per patient per year

Frequency of Vists/Year  Patients n (%)  Visits/Year n (%)  
1-2  83 (57.6)  96 (14.8) 
3-5  30 (20.8)  112 (17.3)  
 6-10  14 (9.7) 109 (16.8)  
11-20  10 (6.9)  139 (21.4)  
21-30 5 (3.5)  117 (18)  
31-40  2 (1.4) 70 (10.8) 
Frequency of Vists/Year  Patients n (%)  Visits/Year n (%)  
1-2  83 (57.6)  96 (14.8) 
3-5  30 (20.8)  112 (17.3)  
 6-10  14 (9.7) 109 (16.8)  
11-20  10 (6.9)  139 (21.4)  
21-30 5 (3.5)  117 (18)  
31-40  2 (1.4) 70 (10.8) 

Note: Each patient did not visit the DH every year (Table 1).

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 (Figure2), 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.

Fig. 2.

Frequency distribution of opioid usage.

At first, 90% of the patients were treated with meperidine, reflecting prior history of the use of this opioid. Later years reflected a decrease in the use of meperidine, with hydromorphone being the second most frequently used opioid in the DH.

Fig. 2.

Frequency distribution of opioid usage.

At first, 90% of the patients were treated with meperidine, reflecting prior history of the use of this opioid. Later years reflected a decrease in the use of meperidine, with hydromorphone being the second most frequently used opioid in the DH.

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).

Fig. 3.

Medication titration to pain relief.

Most visits (84%) resulted in relief of pain (score of 2 or greater on a scale of 0-4) over the 5-year period, as previously described (A). Of patients attaining relief, 60% experienced relief within 2 hours, and 90% experienced relief within 4 hours (B). Patients who had 1 to 5 visits per year experienced a greater magnitude of relief in half the time compared with patients who had more than 5 visits per year (C).

Fig. 3.

Medication titration to pain relief.

Most visits (84%) resulted in relief of pain (score of 2 or greater on a scale of 0-4) over the 5-year period, as previously described (A). Of patients attaining relief, 60% experienced relief within 2 hours, and 90% experienced relief within 4 hours (B). Patients who had 1 to 5 visits per year experienced a greater magnitude of relief in half the time compared with patients who had more than 5 visits per year (C).

Side effects, such as nausea, pruritus, vomiting, or sedation, were experienced in 20% of the patients treated in the DH. Pruritus occurred most often following administration of hydromorphone. Seizures, clonus, or respiratory depression were not observed.

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 (Figure4). 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.

Fig. 4.

Hospitalization rate for direct visits to the ED and the DH.

During the year prior to opening the DH, ED dispositions resulted in a 92% hospital admission rate. During year 1 of the study, the ED admission rate was 70% of visits; over the next 4 years, the average ED admission rate decreased to 48%. DH admission rate varied from 2%-11%. When ED and DH visits were combined, 50% of the overall admissions represented a 40% decrease in admission rate since the opening of the DH.

Fig. 4.

Hospitalization rate for direct visits to the ED and the DH.

During the year prior to opening the DH, ED dispositions resulted in a 92% hospital admission rate. During year 1 of the study, the ED admission rate was 70% of visits; over the next 4 years, the average ED admission rate decreased to 48%. DH admission rate varied from 2%-11%. When ED and DH visits were combined, 50% of the overall admissions represented a 40% decrease in admission rate since the opening of the DH.

The average LOS in the DH was 4.5 hours (range, 2 to 7 hours), while the average LOS in the ED was 13 hours (range, 11 minutes to 90 hours). During the 5-year period, the average LOS in the ED remained fairly constant for the dispositions of admissions (13-16 hours) and discharge home (11-13 hours). Treatment time in the ED before transfer to the DH decreased each year, ranging from 16 hours in year 1 to 8 hours in year 5.

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 (Figure5).

Fig. 5.

Dispositions of direct visits only to the ED and DH.

Dispositions are based on the frequency of visits (1-5 and more than 5) per patient per year. The ED admitted 60% of the patients who had 1-5 visits per year and 45% of the patients who visited more than 5 times per year. The DH admitted 5% and 2.5% of the patients, respectively.

Fig. 5.

Dispositions of direct visits only to the ED and DH.

Dispositions are based on the frequency of visits (1-5 and more than 5) per patient per year. The ED admitted 60% of the patients who had 1-5 visits per year and 45% of the patients who visited more than 5 times per year. The DH admitted 5% and 2.5% of the patients, respectively.

To correct for potential differences in severity between patients seen in the ED and DH, patients without comorbidities were compared. For each facility, patients discharged home and patients admitted without comorbidities were combined to represent their respective uncomplicated pain populations. The majority of visits, 70% (1818) of the ED visits and 80% (2033) of the DH visits, were for uncomplicated pain. Of the patients with uncomplicated pain, 776 out of 1818 ED patients (42.7%) were admitted to the hospital, and 168 out of 2033 DH patients (8.3%) were admitted.

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).

The grand total savings, therefore, amounts to more than $1.7 million, which makes this operation financially sound. Of note is the fact that we cannot assess in monetary terms the impact of a less crowded ED and the decrease in suffering due to more rapid control of pain.

Discussion

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 

The underpinning to this approach is immediate assessment and treatment. Each subsequent treatment decision was preceded by and based upon assessments of pain, psychological distress (mood), response to therapy (relief), and adverse effects (sedation). Medication titration to pain relief individualizes care through prompt reassessment and treatment at regular frequent intervals. This approach is preferable to (1) customary rote prescription of the same drug, dose, and interval for each event; (2) as-needed dosing, which permits pain to recur before treatment is provided; or (3) prejudicial exclusive use or avoidance of a particular analgesic.17,23,43 

There is bias against opioid use in pain management, and this bias is a well-recognized factor in undertreatment, even before drug preferences present obstacles to management. These biases are amplified in certain racial groups44,45 and in persons who have frequently recurring acute and/or chronic pain.46-48 Data show that African Americans and Hispanic Americans are undermedicated for their pain to a greater extent than their Caucasian counterparts.44,45 Our personnel were particularly sensitized to these issues because the majority of our patients with sickle cell anemia are either African American or Hispanic American (Table 1), the mainstay of therapy is opioid analgesics, and a few patients account for most of the pain visits.

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.50 51 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.56,57 

The 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.

In conclusion, a dedicated facility for the treatment of uncomplicated painful crises, operating on principle-based pain management, can reduce the time to pain relief, increase the number of patients discharged home, decrease the hospitalization rate, lessen the use of the ED, help integrate care, and positively impact use in other areas. Hence, a dedicated DH appears to be an advantageous multidisciplinary alternative care facility for the acute care of uncomplicated painful crises in sickle cell disease patients. The approach presented is applicable in various clinical settings. The most critical elements include having a dedicated facility and leadership adapted to the various types, sizes, or locations of the institution (urban, suburban, or rural).

Acknowledgments

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.

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.

References

References
1
Reid
CD
Charache
S
Lubin
B
Johnson
CS
Ohene-Frempong
K
Management and Therapy of Sickle Cell Disease.
1995
US Dept of Health and Human Services
Rockville, MD
NIH Publication 95-2117.
2
Platt
OS
Brambilla
J
Rosse
WF
et al. 
Mortality in sickle cell disease. Life expectancy and risk factors for early death.
N Engl J Med.
330
1994
1639
1644
3
Shapiro
BS
Management of painful episodes in sickle cell disease.
Pain in Infants, Children and Adolescents.
Schechter
NL
Berde
CB
Yaster
M
1993
385
Williams and Wilkins
Baltimore, MD
4
Benjamin
LJ
Conventional and experimental approaches to the management of acute vaso-occlusive pain.
Sickle Cell Disease, Pathophysiology, Diagnosis, and Management.
Mankad
VN
Moore
RB
1992
248
Praeger Publisher
Westport, CT
5
Embury
SH
Hebbel
RP
Mohandas
N
Steinberg
Sickle Cell Disease: Basic Principles and Clinical Practice.
1994
Raven Press Ltd.
New York, NY
6
Kaul
DK
Fabry
ME
Nagel
RL
The pathophysiology of vascular obstruction in the sickle syndromes.
Blood Reviews.
10
1996
29
44
7
Francis
RB
Jr
Johnson
CS
Vascular occlusion in sickle cell disease: Current concepts and unanswered questions.
Blood.
77
1991
1405
1414
8
Ballas
SK
The sickle cell painful crisis in adults: phases and objective signs.
Hemoglobin.
19
1995
323
333
9
Nadel
C
Portadin
G
Sickle cell crisis: Psychological factors associated with onset.
NYS J Med.
77
1977
1075
1078
10
Gil
KM
Coping with sickle cell disease pain.
Ann of Behavioral Med.
11
1989
49
11
Whitten
CF
Fischoff
J
Psychosocial effects of sickle cell disease.
Arch Int Med.
133
1974
681
689
12
Vichinsky
EP
Johnson
R
Lubin
BH
Multidisciplinary approach to pain management in sickle cell disease.
Am J Ped, Hem/Oncol.
4
1982
328
333
13
Treadwell
MJ
Gil
KM
Psychosocial aspects.
Sickle Cell Disease: Basic Principles and Clinical Practice.
Embury
SH
Hebbel
RP
Mohandas
N
Steinberg
MH
1994
517
Raven Press Ltd.
New York, NY
14
Platt
OS
Thorington
BD
Brambilla
DJ
et al. 
Pain in sickle cell disease: Rates and risk factors.
N Engl J Med.
325
1991
11
16
15
Gebhart
GF
Hammond
DL
Jansen
TS
Proceedings of the 7th World Congress on Pain, Progress in Pain Research and Management.
2
1994
IASP Press
Seattle, WA
16
Melzack
R
The tragedy of needless pain.
Sci Am.
262
1990
27
33
17
Jacox
A
Carr
DB
Payne
R
et al. 
Clinical Practice Guideline No. 9: Management of Cancer Pain.
1994
US Agency for Health Care Policy and Research
Rockville, MD
AHCPR Publication 94-0592.
18
Principles of analgesic use in the treatment of acute pain and cancer pain.
3rd ed.
1992
American Pain Society
Skokie, IL
19
Jaffe JH. Drug addiction and drug abuse. In: Goodman, Rall, Nies, Taylor, eds. The Pharmacological Basis of Therapeutics. NY, Pergamon Press; 1990:552.
20
Marks
RM
Sachar
EJ
Undertreatment of medical inpatients with narcotic analgesics.
Ann Int Med.
78
1973
173
181
21
Charache
S
Terrin
ML
Moore
RD
et al. 
Effect of hydroxyurea on the frequency of painful crises in sickle cell anemia. Investigators of the multicenter study of hydroxyurea in Sickle Cell Anemia.
N Engl J Med.
332
1995
1317
1322
22
Benjamin
LJ
Sickle cell pain.
Advances in Pain Research and Therapy, the Design of Analgesic Clinical Trials.
Max
M
Portenoy
R
Laska
EM
1990
317
Raven Press Ltd.
New York, NY
23
Foley
KM
The treatment of cancer pain.
N Engl J Med.
313
1985
84
95
24
Payne
R
Pain management in sickle cell disease: Rationale and techniques.
Sickle Cell Disease.
Whitten
C
Bertles
J
1989
Annals of NY Academy of Science
New York, NY
: 565.
25
Thomas PF, Abrams M, Johnson-Telfair A, Firch K, Murphy M, Rosse W. Issues in Emergency Room treatment of sickle cell disease: The patient's perspective. 20th Annual Meeting of the National Sickle Cell Disease Program, Boston, MA; March 18-25, 1995:108.
26
Alleyne
J
Thomas
VJ
The management of sickle cell crisis pain as experienced by patients and their carers.
J Adv Nurs.
19
1994
725
732
27
Koshy
M
Leikin
J
Dorn
L
Lebby
T
Talischy
N
Telfert
MC
Evaluation and management of sickle cell disease in the emergency department (an 18-year experience):1974-1992.
Amer J Therapeutics.
1
1994
309
28
Moore D. Patient/physician model for painful crises: an alternative pathway for care. Presented at: 19th Annual Meeting of the National Sickle Cell Disease Program. Pain Symposium; March 23-26, 1994; New York, NY.
29
Cousins
M
Acute and post-operative pain.
Textbook of Pain.
Wall
B
Melzack
R
1989
284
Churchill Livingstone
New York, NY
30
Fishman
B
Pasternak
S
Wallenstein
SL
Houde
RW
Holland
JC
Foley
KM
The Memorial Pain Assessment card: A valid instrument for the evaluation of cancer pain.
Cancer.
60
1987
1151
1158
31
Cleeland
CS
Ryan
KM
Pain assessment: Global use of the brief pain inventory.
Ann Acad Med Singapore.
23
1994
129
138
32
Benjamin LJ, Edwards KR, Swinson GI, Cleeland CS. Use of the Brief Pain Inventory Short Form (BPISF) for assessment of acute sickle cell pain. Presented at: 21st Annual Meeting of the National Sickle Cell Disease Program; March 6-9, 1996; Mobile, AL. p 84.
33
Bruera
E
Branneis
C
Paterson
AH
MacDonald
RN
Use of methylphenidate as an adjuvant to narcotic analgesics in patients with advanced cancer.
J Pain Symptom Manage.
4
1984
3
6
34
Shapiro
BS
Cohen
DE
Howe
CJ
Patient-controlled analgesia for Sickle cell related pain.
J Pain Symptom Manage.
8
1993
22
28
35
Holbrook
CT
Patient-controlled analgesia pain management for children with sickle cell disease.
JAAMP.
1
1990
93
96
36
Romberg
PA
Pulmonary aspects of sickle cell disease.
Arch Int Med.
133
1974
652
37
Embury
SH
Garcia
J
Mohandas
N
Pennathur Das
R
Clark
MR
Effects of oxygen inhalation on endogenous erythropoietin kineticsm erythropoiesis, and properties of blood cells in sickle cell anemia.
N Engl J Med.
2311
1984
291295
38
Reinhard
EH
Moore
CV
Dubach
R
et al. 
Depressant effects of high concentration of inspired oxygen on erythrocytogenesis: Observations on patients with Sickle Cell Anemia with description of observed toxic manifestations of oxygen.
J Clin Invest.
23
1944
682
39
Gil
KM
Phillips
G
Abrams
MR
Williams
DA
Pain drawings and sickle disease pain.
Clin J Pain.
6
1990
105
109
40
Ransford
AO
Cairno
D
Mooney
V
The pain drawing as an aid to the psychologic evaluation of patients with low back pain.
Spine.
1
1972
127
41
Benjamin
LJ
Pain in sickle cell disease.
Current Therapy of Pain. Ontario, Canada: B.C.
Foley
K
Payne
R
1989
90
Inc.
Decker
42
Ferrell
BR
Griffith
H
Cost Issues Related to Pain Management: Report from the Cancer Pain Panel of the Agency for Health Care Policy and Research.
J Pain Symptom Manage.
9
1994
221
234
43
Brookoff
D
Polomano
R
Treating sickle cell pain like cancer pain.
Ann Intern Med.
116
1992
364
368
44
Todd
KH
Samaroo
N
Hoffman
JR
Ethnicity as a risk factor for inadequate emergency department analgesia.
JAMA.
269
1993
1537
1539
45
Cleeland
CS
Gonin
R
Baez
L
Loehrer
P
Pandya
KJ
Pain and treatment of pain in minority patients with cancer.
Ann of Int Med.
127
1997
813
816
46
Gil
KM
Phillips
G
Edens
J
Martin
NJ
Abrams
M
Observation of pain behaviors during episodes of sickle cell disease pain.
Clin J Pain.
10
1994
128
132
47
Armstrong
ED
Pegelow
CH
Gonzalez
JC
Martinez
A
Impact of children's sickle cell history on nurse and physician ratings of pain and medication decisions.
J Pediatric Psychol.
7
1995
651
664
48
Grossman
SA
Sheidler
VR
Swedeen
K
Mucenski
J
Piantadvosi
S
Correlation of patient and care giver ratings of cancer pain.
J Pain Symptom Manage.
6
1991
53
57
49
Galer
BS
Coyle
N
Pasternak
GW
Portenoy
RK
Individual variability in the response to different opioids: report of five cases.
Pain.
49
1992
87
91
50
Tang
RS
Shimomura
SK
Rotblatt
M
Meperidine-induced seizures in sickle cell patients.
Hosp Formul.
15
1980
764
Kaiko RF, Foley KM, Grabinski PY, et al. Central nervous system excitatory effects of meperidine in cancer patients. Ann Neurol. 1989;13:180185.
52
Wall
PD
The prevention of post-operative pain.
Pain.
33
1988
289
290
53
Benjamin
LJ
Swinson
GI
Fulchon
C
McKegney
F
Frequently recurring pain in sickle cell disease.
Sickle Cell Disease and Thalassaemias: New Trends in Therapy.
Beuzard
Y
Lubin
B
Rosa
J
234
1994
433
Colloque Inserm
Paris, France
54
Davis
H
Moore
RM
Gergen
PJ
Cost of hospitalizations associated with sickle cell disease in the United States.
Public Health Report.
112
1997
40
43
55
Wood
K
Karrison
T
Koshy
M
Patel
A
Friedmann
P
Cassel
C
Hospital utilization patterns and costs for adult sickle cell patients in Illinois.
Public Health Report.
112
1997
44
56
Serjeant
GR
Ceulaer
CD
Lethbridge
R
Morris
J
Singhal
A
Thomas
PW
The painful crisis of homozygous sickle cell disease: clinical features.
Brit J Haem.
87
1994
586
591
57
Platt A, Eckman J. The cost and benefits of operating a 24 hour comprehensive sickle cell center [abstract]. Presented at the 18th Annual Meeting of the National Sickle Cell Disease Program, Philadelphia, PA; May 23-25, 1993.
58
Cleeland
CS
Analgesic trials to clinical practice. When and how does it happen?
Advances in Pain Research and Therapy.
Max
M
Portenoy
R
Lasko
E
18
1991
Raven Press Ltd.
New York, NY
59
Miaskowski
C
Nichols
R
Brody
R
et al. 
Putting the cancer pain guidelines into practice.
Capsules and Comments in Oncology Nursing.
3
1995
9
15
60
Max
M
Improving outcomes of analgesic treatment: Is education enough?
Annals Intern Med.
113
1990
885
9
61
Dahl JL, Berry PH, Skemp MM, Patterson CH, Wuest JM. Institutionalizing Pain Management: Making Pain Assessment and Treatment an Integral Part of the JCAHO's Standards and Survey Process [abstract]. Presented at: 9th World Congress on Pain, International Association for the Study of Pain; August 22-27, 1999, Vienna, Austria. IASP Press 472.