A Multicenter Review of Quality Care Metrics for Patients with Sickle Cell Disease Presenting to Community Hospitals in Southwestern Ontario

Introduction: While sickle cell disease (SCD) represents the most common inherited hemoglobinopathy, patients with SCD have been subjected to healthcare resource disparity for a multitude of reasons, including a lack of healthcare provider awareness of the disease and its complications. In Ontario, Canada, quality standards have been developed to address these inequities and promote prompt delivery of care for patients with SCD presenting to the hospital; however, uptake of these care metrics into routine clinical practice is variable. Most of the efforts toward SCD care optimization have been focused on establishing protocols in tertiary care academic centers to guide the recognition and management of acute SCD complications, such as vaso-occlusive crises (VOC) which represent the primary presenting morbidity associated with SCD. However, many Canadian patients seek care from community-based institutions where SCD care pathways may be lacking. Our study aims to better understand the quality of care provided to patients with SCD presenting to community hospitals by measuring care metrics defined by current guidelines.

Methods: A retrospective chart review of adult patients (18 years of age and older) with SCD who presented to Emergency Departments (EDs) in southwestern Ontario, Canada, between January 2018 and December 2023. We evaluated patient presentations to Windsor Regional Hospital (WRH) and Erie Shores HealthCare (ESHC), encompassing the major community hospitals across southwestern Ontario. We assessed time from ED triage registration to analgesia delivery, type of analgesia, inpatient admission rates, ED return within 72 hours of discharge, and documented follow-up at discharge. Quality care metrics were entered into an institutional REDCap database and descriptively analyzed.

Results: Thirty-two ED visits corresponding to thirteen unique patients occurred between 2018-2023 across three hospital sites. The median age at ED visit was 25.9 years [interquartile range (IQR) 22.4, 29.4], with most patients being male (n=25; 78.1%). VOC represented the most common reason for ED visit (n=23; 71.9%), followed by hepatobiliary disease (n=3; 9.4%), acute chest syndrome (n=2; 6.3%), and priapism (n=2; 6.3%). The median length of ED stay was 14.1 hours (IQR 8.7, 19.1). The median time from ED triage registration to analgesia delivery was 4.1 hours (IQR 1.8, 7.7). None of the patients presenting with VOC received analgesia within 30 minutes of triage registration, and only 2 (8.7%) received analgesia within the first hour. Twenty-six patients (81.25%) received intravenous opioids, 8 (25%) were given NSAIDs, and 11 (34.4%) received acetaminophen; most patients (61.5%) received opioids alone. Eighteen patients (56.3%) required admission to the hospital from ED, with a median length of inpatient stay of 72 hours (IQR 40.1, 106.3). Among the 14 patients (43.7%) discharged home from the ED, 14.3% returned to the ED within 72 hours of discharge.

Conclusions: Most patients with SCD presenting to community hospitals in southwestern Ontario, Canada are not receiving the quality standards of care set forth by the Ontario Ministry of Health or American Society of Hematology (ASH) guidelines. Patients presenting with VOC should ideally be treated within 30 minutes of ED triage registration, which did not occur in any patients in our cohort. Moreover, most patients were treated with opioids alone as opposed to a multimodal analgesia approach, and the organization of Hematology follow-up at discharge was variably described. We aim to use these data to advocate for enhanced resources for patients with SCD in our region and community hospitals, in general, to promote streamlined delivery of care for patients presenting to the ED.

No relevant conflicts of interest to declare.