Day Hospital

Intermittent episodes of pain are the most consistent manifestation of sickle cell disease. Pain management involves care of both acute and chronic pain. One of the important interventions that has improved the care of patients with sickle cell disease is the institution of a day hospital where acute episodes of pain can be managed without resorting to emergency room care. Many, if not most, episodes of acute vaso-occlusive crisis pain can be controlled such that patients can return home if immediate and aggressive intervention with intravenous analgesics and fluids is undertaken. The day hospital offers at least two advantages over the emergency room. First, treatment can begin quickly, often within minutes of the patient's arrival. The nature of emergency room care means that patients with vaso-occlusive crisis pain may wait for long time periods for evaluation and treatment. Almost as a matter of course, the patient's frustration increases with the rising pain levels during this time. The interaction of an often harried ER physician and a patient with sickle cell disease who has waited for hours to be seen frequently is not congenial.

A second advantage of the day hospital is the staff is familiar with the patients and their analgesic requirements for pain control. This is a key issue in the care of patients with sickle cell disease, some of whom require chronic outpatient therapy with opioids. These patients become tolerized to opioids, and require larger doses of medications than do naive patients. The rotating nature of the staff in most emergency rooms means that patients with sickle cell pain crises often see different providers with each visit. Consequently, patients frequently are undermedicated. An ER physician may (reasonably) be cautious with an unfamiliar patient and begin with 2 mg of intravenous hydromorphone (Dilaudid®), when the patient might require 8 mg every 45 minutes for a total of 5 doses to achieve adequate analgesia. This scenario often evokes a confrontation between patient and staff. The patient demands more medication since the administered amount is inadequate. The staff becomes defensive, and begin to question whether the patient is simply seeking drugs. Hostility develops on both sides. In this context, which is unpleasant for patient and staff, reasonable medical care is not possible.

These factors combine to increase the admission rate to the hospital for patients who are treated for vaso-occlusive pain in the ER versus the day hospital. Dr. Lenette Benjamin presented data from Montefiore Hospital in the Bronx at the 21st Annual Meeting of the Comprehensive Sickle Cell Centers in March, 1999. Over a period of five years, the relative rates of admission for vaso-occlusive pain crises of patients seen in the ER and those seen in the day hospital were 56% and 12% respectively. The lower admission rate from the day hospital saved the hospital about one-half million dollars during this time. For communities with substantial numbers of patients with sickle cell disease, a day hospital treatment facility makes sense both from financial and medical points of view.