Implementation of a Pediatric Observation Unit for Children with Sickle Cell Disease
Authors: Sharifali Sophia , Sturgis Lashon , Neunert Cindy , Lane Natalie , Gibson Robert , Lyon Matthew 
Published: October 2019

Abstract

Acute vaso-occlusive crisis (VOC), the most common manifestation of Sickle Cell Disease (SCD), is the number one cause for visits to the Emergency Department (ED). Pediatric patients differ from adult patients with SCD due to variations in opioid tolerance and age-specific complications. Many pediatric patients can be sent home after evaluation and treatment in an ED, however, others will need hospitalization for further pain management as well as continued evaluation.
Observation Units (OUs), ED-associated units for evaluation and protocol management of short-term conditions (<24 hours), have successfully provided more rapid care while still maintaining quality. At our institution, using an OU-based protocol, we have demonstrated improved care with decreased resource utilization in an adult population with SCD experiencing VOC. However, there is limited data for the use of OU in pediatric patients with VOC. Our objective was to determine the feasibility of a pediatric OU for the evaluation and treatment of patients with uncomplicated VOC.
A retrospective, descriptive chart review study was conducted on all pediatric patients (<18 years) with SCD between July 1, 2012 to June 30, 2013. The study was conducted in an academic pediatric tertiary care hospital (annual volume 27k/year). A medical record search was conducted using ICD-9 codes and SCD related DRG codes. The cohort was then limited to patients who received care in the academic ED or were transferred from another hospital for direct admission (DA). The cohort was limited to visits with pain related to VOC. Patients with a complication other than VOC were excluded as well as patients admitted to the intensive care unit. Cohort data as well as exclusion criteria are in table 1.
Visits that were admitted to the floor (either as a direct admission or admitted from the ED) with a length of stay (LOS) less than 48 hours were included in the analysis. Patients were grouped into categories based on LOS: < 24 hours, <36 hours, and <48 hours Though the OU will only manage up to 24 hours, categories of LOS longer than 24 hours were included in order to capture elements that may lengthen a patients stay such as waiting time, time until disposition and discharge.
Table 1. Sample Size and Exclusion Criteria # of Patients treated for Sickle Cell Between 7/1/2012 - 6/30,2012 197 patients Limiting to patients seen in ED or having a DA 119 patients Limiting to confirmed diagnosis of SCD (multiple genotypes) = 6 113 patients Limiting to reason of visit to a pain complaint = 6 107 patients Limiting to reason of pain to VOC = 3 104 patients Limited or no data in EMR (left prior to treatment) = 3 101 patients Exclusion of patients with visits only for complications of SCD* = 21 80 patients Final Sample Size for analysis 80 patients
*Complications include acute chest syndrome, sepsis, splenic sequestration, fever, infiltrates, and infection
80 patients had 160 visits for uncomplicated VOC from 7/1/2012 - 6/30/2012. Of the 160 visits, the patient was admitted53.8% (86) of the time. Of the 86 visits resulting in admission, 30 (34.9%) were DA and 56 (65.1%) were admitted from the academic ED. LOS of the admission by DA or from the academic ED is in table 2.
Table 2. LOS for Admissions DA to Floor 30 total visits LOS < 24 Hours 5 (16.6%) visits LOS < 36 Hours 10 (33.3%) visits LOS < 48 Hours 17 (56.7%) visits ED to Floor 56 total visits LOS < 24 Hours 4 (7.1%) visits LOS < 36 Hours 10 (17.9%) visits LOS < 48 Hours 21 (37.5%) visits
OU's are ideal for the evaluation and management of patients requiring more than a few hours of ED treatment but less than 24 hours of hospital therapy. Our study shows that there is a large number of patients with SCD and VOC are admitted (53.8%). Based on our study, 44% of admissions have a LOS less than 48 hours. We believe that 48 hours is a reasonable cutoff for consideration of OU care as disposition decisions on the floor occur at 12-hour and sometimes 24-hour intervals leading to an increase in LOS beyond the actual treatment time. All patients, including DA patients, should be eligible for OU treatment if they meet inclusion criteria. This is evidenced by the finding that the LOS is shorter for DA patients (56.7%) versus admissions from the academic ED (37.5%).
Overall, pediatric SCD patients would benefit from the presence of a pediatric OU by potentially decreasing the rate of inpatient admissions. An observation unit should therefore be strongly considered in centers with large volume SCD.

Disclosures
No relevant conflicts of interest to declare.