Early outcomes with a standardized admission order set for sickle cell crisis: A real-world single-institution retrospective review

Abstract

Abstract Introduction: Sickle cell disease (SCD) is an inherited disorder affecting the beta-globin gene encoding the beta-globin subunit of a hemoglobin molecule. This leads to crescent shape or ‘sickling’ of the red blood cells. Triggers for ‘sickling’ like dehydration, infection, stress, or hypoxemia - can precipitate vaso-occlusion and result in sickle cell crisis due to blockage of blood flow by sickle cells to essentially any organ of the body. This often leads to frequent admissions for a ‘pain crisis’, acute chest syndrome, stroke, renal dysfunction. A previous retrospective audit at our institution underscored inpatient care distinction between patients on the hematology service as compared to general medicine service . To address these gaps in care, we created a standardized Adult Sickle Cell admission order set at our institution aimed at improving care for sickle cell patients. Methods: We performed a retrospective review of the usage of our ‘Adult sickle cell crisis admission’ order set between June 2024 and July 2025 at SUNY Upstate University Hospital. Data for usage was provided by our IT team using SlicerDicer after IRB waiver. Clinical data was extracted from EPIC EMR. The order set was created through a collaborative effort by hematologists at our institution and included medications like a reminder to reorder home hydroxyurea if appropriate, daily folic acid tablets, adjunct pain medications and options for opioid pain regimens, options for hypotonic and regular intravenous (IV) fluids to order on admission, labs on admission, daily labs some of which were pre-selected, quick access to order bowel regimens, deep vein thrombosis (DVT) prophylaxis and incentive spirometry. Time to adequate pain control was calculated (defined as time in hours from admission to a patient-reported pain score of 3 or lower on a numerical rating scale out of 10). Z score for proportions was used to calculate p values comparing our results to the prior institution audit (n=1404 patients) Results: The ‘Adult sickle cell crisis admission’ order set was used 25 times in this time period. The mean age was 32 years; 52% were male and 100% were of African American race. The median Charlson Deyo comorbidity index was 1 (vs 0 in the pre-intervention study). Mean length of hospital stay was 7 days (range 1 - 25 days), 4% of patients required ICU level of care (vs 3.8% in the pre-intervention study, p=0.96) and 3 other patients required ICU monitoring for ketamine infusion per institute policy. Time to adequate pain control was 69.2 hours. 76% of patients were placed on patient-controlled analgesia (PCA) on admission (vs 22% in the pre-intervention study, p=<0.0001). 100% of patients with home hydroxyurea had it resumed on admission, 100% of patients had a bowel regimen (vs 79.1% in the pre-intervention study, p=0.01), and 100% had a form of DVT prophylaxis ordered on admission (vs 73.9%% in the pre-intervention study, p=0.003). Moreover, 92% had incentive spirometry ordered on admission. 40% of patients had a pain service consultation during admission (vs 20.2% in the pre-intervention study, p=0.015), and 4% developed a new DVT/PE during admission. 96% had IV fluids ordered on admission (vs 94.8% in the pre-intervention study, p=0.787) with a mean rate of fluids of 113 ml/hour. The mean hemoglobin was 8.8 mg/dl on admission and 9.0 mg/dl on discharge. Conclusion: Our single institute study demonstrates improvement in sickle cell crisis quality of care measures especially with higher admission order metrics such as DVT prophylaxis, bowel regimen, IV fluids and usage of PCA for adequate pain control. There was no change in requirement of escalation to ICU level fo care and an increase in the mean duration on PCA post intervention. This single institution experience underscores the potential for distinction of sickle cell care between different providers and provides a standardized plan of care to optimize sickle cell inpatient care.1. Bou Zerdan M, Niforatos S, Ashok Kumar P, et al. Distinguishing the variances in patient care between hematologists and hospitalists for individuals with sickle cell disease hospitalized due to Vaso-occlusive crisis. Blood. 2023;142(Supplement 1):3675–3675.