LAUSR

Much attention has been directed toward super utilizers of emergency department (ED) and hospital services. Often these patients have a chronic illness with significant potential for acute morbidity. In many settings, adults with sickle cell disease (SCD) are a significant proportion of super utilizers. This population has a significantly shortened life span compared to other adults as well as a high morbidity including acute life-threatening diseases such as acute chest syndrome and stroke. Compared to other chronic diseases, SCD patients have significantly higher 1 admission and readmission rates, and outpatient resources are often poorly available. 2 Quality and uniformity of care across clinical locations is often questioned. Recent authors have highlighted that there are significant differences between specialists in the approach to pain management with vaso-occlusive crisis. This includes differences between hospitalists trained in internal medicine and hematologists. 3 Other authors have highlighted the difficulty of consistently providing high quality education to sickle-cell patients and their families. High utilizers of hospital services are often characterized by significant social and psychiatric challenges both in the SCD patient and in the supporting family. 4 In this edition of Western Journal of Emergency Medicine 5 Simpson et. al. describe an intervention to enroll ED super utilizers with SCD in an ED management protocol and the formation of a medical home. The effort required for this intervention is significant and needs to be emphasized. This multidisciplinary clinic included a primary care doctor, social worker, addiction and pain specialist, pharmacist and psychologist. They demonstrated that ED utilization and length of stay, as well as admission rate and inpatient length of stay, can all be decreased using this method. Mortality and ICU readmission did not occur in the study group, but the small sample prevents an adequate statistical analysis. Such a targeted approach, which coordinates ED, inpatient and outpatient settings, is ideal for managing a chronic illness with significant potential for acute morbidity. Other authors have highlighted the need for coordinated care and alternatives for ED management of exacerbations of SCD. Alternatives should be prompt and available a large number of hours to sufficiently replace the convenient 24/7 access of the ED. 6 The level of care must be appropriate for any reasonable acute exacerbation of SCD. Specialty infusion centers have been proposed by a large number of authors 7 and have demonstrated significant decrease in admission rates. Such centers require individual care plans, and support …