MUSC creates protocol to improve emergency care for pediatric sickle cell patients

The Pediatric Emergency Medicine and Pediatric Hematology/Oncology divisions at the Medical University of South Carolina (MUSC) joined forces to create and test an algorithm for treating children with sickle cell disease who present to the Emergency Department (ED) with a fever.

With the new algorithm, emergency physicians at MUSC Shawn Jenkins Children's Hospital confer with the hematology/oncology team to determine patients' levels of risk, recommending that low-risk patients be treated as outpatients. The algorithm creates a consistent and standardized pathway of care that could reduce hospitalizations.

Early data on the rollout of this algorithm was published in March in the Journal of Pediatric Hematology and Oncology. Statistical support for the study was funded by the South Carolina Clinical & Translational Research Institute.

We were thrilled to partner with our ED colleagues and with the MUSC Value Institute to create a treatment pathway to streamline care for our patients with sickle cell disease and safely reduce the burden of repeated hospitalizations for their families."

Michelle Hudspeth, M.D., senior author, division chief for Pediatric Hematology/Oncology at MUSC Children's Health

Sickle cell disease is a genetic, lifelong condition that affects red blood cells, causing them to become sickle-shaped and block blood flow to other parts of the body. This disease is most seen in people of African descent. According to the National Heart, Lung, and Blood Institute, patients with sickle cell disease face lifelong health complications, such as chronic pain, lung problems and poor function of the spleen.

"Your spleen does a lot of things," said first author Jason Erno, M.D., who joined the project as a first-year medical student and continued through his first year of residency. "One of the most important is to help to prevent infections."

That's why it's so important to monitor for infections in young children with sickle cell disease, explained Erno, who is now a second-year resident in internal medicine at the University of Virginia.

"These kids are susceptible to more severe infections than your average kid, which is why it can be so scary when they get sick," he said. Historically, any sickle cell disease patient under 2 years old who came to the ED with a fever would be admitted to the hospital immediately. This practice resulted in a high number of unnecessary and burdensome hospital stays. These stays cost both the patient's family and the hospital time and money.

Hudspeth explained that hospitals across the country are transitioning the admission age from 2 years to 1 year with additional criteria, citing the increased protection of vaccinations.

"That's what we sought to do here – see if we could safely reduce the age of required admission for fever with a clearly standardized protocol that included predefined risk factors," Hudspeth said.

Co-author of the article, MUSC Children's Health pediatric hematologist/oncologist Shayla Bergmann, M.D., agreed. "This algorithm safely allows our care of these patients to align with national thoughts and practice while also considering quality of life for our patients and their families."

The interdisciplinary team came together to create an agreed-upon diagnostic algorithm that would inform the decision for admitting or discharging a pediatric patient with sickle cell disease and a fever. Their goal was to discharge safely patients who could recover at home with close follow-up.

The research team implemented the algorithm for a year and compared admissions data for that year with the year prior, seeing a 10% decrease in admissions with no difference in readmissions. Though not statistically significant, these findings suggested that low-risk patients could be treated safely as outpatients, and the close follow-up could be working.

"Having the algorithm makes everybody feel a little more comfortable that we're doing the right thing," Erno commented.

The algorithm continues to be used and studied at MUSC Children's Health. Its success, Bergmann said, highlights the power of collaboration and proves that improved patient care doesn't have to come at a price. "It lessens the burden of hospital stays and complications," she said, "and it lowers time missed from work for parents and caregivers."

The interdisciplinary team put incredible amounts of time and effort into developing and testing this important tool. The team is satisfied with having a standardized protocol in place, and everyone is optimistic that their young patients will also see the impact. To change the course of care for their patients, Erno, Bergmann and Hudspeth reiterated the same hopeful outcome: more home days. Fewer hospital stays.