Quality Improvement Project to Evaluate Fever Management and Appropriateness of Lab Draws in Hospitalized Sickle Cell Disease Patients in a Tertiary Care University Teaching Hospital

Introduction: Sickle cell disease is the most common inherited blood disorder that affects almost 100,000 people in the U.S. Infection is the most common cause of death in these patients. Early identification and initiation of antibiotics given functional asplenia is the key to appropriate management of hospitalized sickle cell disease patients. Approximately 4-5 billion laboratory studies are ordered every year in hospitals. Unnecessary blood tests lead to frequent blood draws and worsening anemia in this already anemic population as well as contribute towards increasing cost of hospital stay. Total national health expenditures in the U.S. is $3.3 trillion (2016) with percent of national health expenditures for hospital care: 32.4%.

Objective: We reviewed inpatient admissions of sickle cell disease patients to assess for appropriate work up and timely antibiotic initiation in case of fever. Additionally, we looked up the number of blood draws as well as number of days labs were drawn during the inpatient stay.

Methods: This was a retrospective chart review of all patients with sickle cell disease who were admitted to John Dempsey hospital at University of Connecticut with length of stay of at least 3 days between April 2018 to Feb 2019.

Results: 57 inpatient admissions were reviewed. Out of 57 admissions, 14 had fever either at the time of presentation or during the hospital stay. Mean time to first blood culture was 56 minutes with 92% (13/14) drawn within 1 hour of fever. Mean time to first antibiotic was 4.58 hours. Antibiotics were initiated in 7% (1/14) in less than 1 hour and 50% (7/14) within 3 hours. Urine culture was checked 78% and chest X-ray was checked 100% of the time in case of fever. On review of 57 patient admissions, labs were checked every single day of hospital stay in 35% (20/57) and if the day of discharge was excluded in 50% (29/57) of the patients. Overall, the labs were checked 82.33 percent of the days patients were hospitalized. On average, labs were drawn 1.14 times per day on each patient.

Conclusion: Our project addresses safety, efficiency and timeliness with identification of areas of improvement in febrile sickle cell disease patients. It also addresses patient-centeredness raising awareness for decreased needle sticks for our sickle cell disease patients. There is continuing need to educate our care providers on how to manage fever in sickle cell disease for appropriate work up and early initiation of antibiotics. Also, we need to be more considerate when ordering labs on our patients especially sickle cell disease patients with baseline anemia. This will lead to decreased number of needle sticks and iatrogenic anemia as well as better healthcare resource utilization.