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A Standardized Clinical Pathway to Decrease Hospital Admissions Among Febrile Children With Sickle Cell Disease

Ellison, Angela M. MD, MSc*; Smith Whitley, Kim MD; Kittick, Marlena MPH*; Schast, Aileen PhD; Norris, Cynthia MD; Hartung, Helge MD; McKnight, Therese CRNP; Coyne, Erin CRNP§; Lavelle, Jane MD*

Journal of Pediatric Hematology/Oncology: March 2018 - Volume 40 - Issue 2 - p 111–115
doi: 10.1097/MPH.0000000000001052
Original Articles
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Background and Objective: Recurrent hospital admissions for patients with sickle cell disease (SCD) are costly and contribute to a low quality of life for patients. We implemented a clinical pathway to safely discharge SCD patients with fever who are evaluated in the emergency department (ED) of a large tertiary care center.

Methods: An interdisciplinary team of ED and hematology physicians, nurses, and an improvement advisor developed a clinical pathway that identified febrile SCD patients at low risk of serious bacterial infection based on historical, clinical, and laboratory criteria who could be discharged from the ED. Phone follow-up was planned through the use of an automated electronic notification that was sent to an established hematology follow-up pool at the time of ED discharge. We conducted two “fake front end” trials in the ED to receive feedback on our process before full implementation. A postpathway implementation quality improvement team monitored discharge rates, phone follow-up rates and adverse events.

Results: In the first 9 weeks postpathway implementation, 100 SCD patients were evaluated for fever; 84 (24%) met low-risk criteria and were discharged home. This reduction in admission rate has been maintained throughout the 3 years postimplementation. Successful phone follow-up was achieved in all discharged patients within 24 hours and no adverse events were identified.

Conclusions: Low-risk febrile patients with SCD can be safely discharged from the ED. An automated notification system within the electronic medical record system can facilitate patient follow-up after ED discharge. Future quality improvement efforts aimed to further reduce admissions in this population should target patients with modifiable risk factors for serious bacterial infection.

Divisions of *Emergency Medicine

Hematology

Office of Clinical Quality Improvement, The Children’s Hospital of Philadelphia, Philadelphia, PA

§Division of Hematology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE

This work was supported by the Office of Clinical Quality Improvement at the Children’s Hospital of Philadelphia.

The authors declare no conflict of interest.

Reprints: Angela M. Ellison, MD, MSc, Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Colket Bldg, 9th Floor, Philadelphia, PA 19104 (e-mail: ellisona@email.chop.edu).

Received November 11, 2015

Accepted July 29, 2017

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