A Clinic to Improve Care of Patients with Sickle Cell Disease and the Role of Medical Students in Quality Improvement

Background: At Hofstra-North Shore LIJ School of Medicine, we have opportunities for our medical students to participate in experiential quality improvement projects. As part of this initiative, some students participate on health-care improvement teams using a Clinical Microsystems approach. This approach is a conceptual framework that has been applied to various departments in the North Shore-LIJ Health System in order to improve quality and patient safety. The basis of Clinical Microsystems is to identify a need in the hospital that may be targeted in order to improve the efficacy of healthcare quality and delivery. Once the objective for healthcare improvement is determined, a multidisciplinary team is created spanning one or more microsystems to target the specific barrier.

One of the multidisciplinary teams focuses on the care of patients with sickle cell disease. LIJ Hospital admits between 150 and 200 patients with sickle cell disease a year primarily due to recurrent pain crises. The initial sickle cell multidisciplinary improvement team included physicians, patients, nurses, social workers and two medical students. The role of the students on this team included literature searches and survey administration. The team's initial analysis found that a lack of consistent outpatient follow up was resulting in frequent readmissions for this population to acute care facilities for pain control. To address this, the team was instrumental in establishing a primary care outpatient clinic focused exclusively on caring for patients with sickle cell disease, run by a primary care physician, in 2012.

The current study was conducted by a medical student, and her mentor, who were original members of the sickle cell improvement team. The study tested the hypothesis that enrolling patients with sickle cell disease in an outpatient clinic with a dedicated physician focused on sickle cell disease management and pain control would decrease the number of admissions this population has for acute care at LIJ. The study also highlights the opportunity to involve medical students in a meaningful way in hands-on quality improvement projects in the early stages of training.

Methods: This was a retrospective study of all adults with sickle cell disease, 21 years or older, who were seen at the primary care outpatient sickle cell clinic. We compared the rates of hospital admissions and length of stay in the one-year prior and one-year after their establishment of care at the clinic. All data was identified through manual and automated searches of the Electronic Health Record.

Results: Since the opening of the clinic in 2012, 107 adults established care at the clinic. Within the first year that a patient began being cared for by the clinic, their admission rate dropped 27%, from an average of 3.775 to 2.75 admissions per year (p=0.0003). There were a total of 151 admissions one-year pre-intervention and 110 admissions one-year post-intervention.

Conclusion: This project supports the value of a dedicated primary care outpatient sickle cell clinic on decreasing the admission rates for patients with sickle cell disease. Within one year of establishing care at the clinic, admissions rates decreased significantly, emphasizing the role of dedicated outpatient primary care in the management of patients with sickle cell disease.

This study also highlights the importance and feasibility of integrating medical students into a quality improvement project early on during medical school. There are opportunities for students to have meaningful roles on hospital based improvement projects and learn quality improvement methodologies. An important component to this success is faculty mentoring to support a student's involvement in the project. The student involved in this study experientially participated in multidisciplinary team-based rapid cycles of change, process mapping, data collection and analysis. Similar projects could offer students an opportunity to participate during medical school in a longitudinal quality improvement project to develop skills they will need as physicians to identify, participate and measure the effects of improvement efforts.