Guideline Implementation Champions Project Archive
2023 Champions
Gabriella Nguyen, MD
Affiliation at Time of Research Study: UT Southwestern Medical Center
Project Title: ReBIDA: Steering Change with COMPASS: Clinical Pathway to Optimize the Management of Pediatric Acute Stroke in Sickle Cell Disease
The American Society of Hematology (ASH) guidelines recommend transfusion within 2 hours for children with Sickle Cell Disease (SCD) presenting with acute neurologic deficits. Due to the observation that transfusion is significantly delayed beyond this timeframe, Dr. Nguyen and colleagues developed a quality improvement initiative, Clinical Pathway to Optimize the Management of Pediatric Acute Stroke in Sickle Cell Disease (COMPASS).
Hematology spearheaded a multidisciplinary team that included Neurology, Transfusion Medicine, Emergency Medicine, and Critical Care. Through this collaboration, the team identified hospital wide barriers frequently encountered in the diagnosis and treatment of these patients. Furthermore, Dr. Nguyen and colleagues recognized large knowledge gaps that provided the opportunity to educate and address misconceptions on management practices.
Ultimately, Dr. Nguyen and her partners were able to utilize a multidisciplinary approach to create an institutional SCD stroke pathway that aligns with evidenced based standards. The ongoing study will evaluate the efficacy of the pathway to reduce the time to transfusion in patients with SCD and stroke or TIA by 20% in 1 year.
Christina Ruiz, MD
Institution: University of California San Diego School of Medicine, Division of Pediatrics, Department of Hematology/Oncology; Rady Children's Hospital San Diego Department of Pediatric Hematology/Oncology
Project Title: Improving the Outpatient Pain Management Plan for Patients with Sickle Cell Disease with Innovative Pain Action Plan
The American Society of Hematology (ASH) best practice guidelines recommend that individuals with sickle cell disease have individualized care plans to effectively begin pain management at home prior to presenting to the emergency room, however, our patients were observed to be calling into the on-call team or presenting to the emergency room without attempting adequate pain control at home. In 2022, an outpatient pain action plan Quality Improvement (QI) project was initiated at RCHSD by Dr. Leah Bruno with the global aim to improve outpatient pain management and quality of life for patients with SCD. An initial approach utilizing the MedAction function in Epic had technical challenges and was not implemented. We identified an existing Epic Asthma Action Plan which could be adapted to a SCD pain action plan (PAP). Meetings with clinical informaticists, pulmonology (consultants), and hematology teams informed the QI tools (process mapping, key driver and Ishikawa diagrams) that we used to design our PDSA cycles. The PAPs were modeled after the existing Asthma Action Plan, with green, yellow, and red zones to indicate different levels of pain management.
Patients were given laminated Youth Acute Pain Functional Ability Questionnaires (YAPFAQ) and a comfort measures sheet to complete prior to their visit with the provider to inform the PAP which included pain medication details and supportive care measures for each zone. PAPs were created within the clinic note at comprehensive clinic visits and then provided to the family as a printed letter in person and via MyChart (if activated). From May 2023 to July 2023, 94% percent (13/14) of patients seen at a comprehensive clinic visit received a PAP. One patient had the PAP created but did not receive the printed letter due to time constraints for family. Early provider feedback has indicated that this functionality is easy to use and efficient during the comprehensive clinic visit.
2022 Champions
W. Andres Vasconez Samaniego, MD
Affiliation at Time of Research Study: Pediatric Residency Training program at the University of Miami/Holtz Children’s Hospital at Jackson Memorial Medical Center, Miami, FL
Current Affiliation: Combined Pediatric Hematology and Oncology Fellowship at the Johns Hopkins University/National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Baltimore and Bethesda, MD
Reducing time to analgesia in the care of Sickle Cell Disease vaso-occlusive events
Dr. Vasconez Samaniego and colleagues investigated the average time to first analgesic dose delivery in the Pediatric ED to patients with Sickle Cell Disease SCD vaso-occlusive pain events and found it was higher than the national recommendation. The most current guidelines from the National Heart Lung Blood Institute and the American Society of Hematology were utilized to streamline pain management in the Pediatric ED at the University of Miami/Holtz Children’s Hospital at Jackson Memorial Medical Center. Following current evidence-based medicine, a multi-disciplinary team assisted health care providers in delivering optimal care to patients with SCD vaso-occlusive episodes.
Time-to-first-analgesic-dose was reduced by 47% with a sustained improvement in Length of Stay through several PDSA cycle interventions that included the creation of a clinical pathway for SCD vaso-occlusive pain events in the Pediatric ED and its integration into the house staff workflow.
Jordan Schaefer, MD, FACP
University of Michigan, Ann Arbor, Michigan
Reducing Excess Aspirin Use Among Patients on Chronic Anticoagulation for Venous Thromboembolic Disease
The 2020 American Society of Hematology (ASH) Guidelines for the Management of Venous Thromboembolism suggest “for patients taking aspirin for primary prevention of [cardiovascular disease] or for stable coronary artery disease, The ASH guideline panel provides a conditional recommendation in favor of suspending aspirin while taking anticoagulant therapy…”. Dr. Schaefer and his colleagues in the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) participated in a quality improvement project starting between October of 2017 and June of 2018 at six diverse clinical sites. They were able to implement this ASH Guideline Recommendation to reduce excess aspirin use among patients anticoagulated for VTE and sustain this effort over several years. Having followed thousands of warfarin anticoagulated patients with VTE, they have shown an over 40% reduction in excess aspirin use. Across MAQI2, reduced aspirin use was associated with improved clinical outcomes without an observed increase in thrombotic outcomes.
Jori E. May, MD
University of Alabama at Birmingham
Improving the Diagnosis and Management of Heparin Induced Thrombocytopenia (HIT) with Automatic Electronic Consultation
Dr. May and her colleagues observed frequent deviation from guideline-supported care in patients with suspicion for and with confirmed heparin-induced thrombocytopenia (HIT). In response, they developed an electronic consultation (e-consultation) system (the “HIT E-consult Service”), in which a hematologist was automatically consulted on all patients with a positive screening immunoassay for HIT. E-consultation was performed via review of the patient medical record, without patient contact, and recommendations were communicated to the consulting team via documentation with telephone conversation as needed.
The HIT E-consult Service consistently recommended against the use of non-heparin anticoagulation in patients with low concern for HIT, resulting in a significant decline in hospital-wide use of bivalirudin, the preferred direct thrombin inhibitor at the institution. The HIT E-consult Service also increased the use of oral factor Xa inhibitors and fondaparinux in appropriate patients. The median length of stay for patients with confirmed HIT decreased with e-consultation from 39 days to 17 days. Additional observed benefits include improve interpretation of complex HIT testing results and increased post-discharge follow-up with hematology for continued face-to-face care.
The efforts of Dr. May and colleagues demonstrate that automatic e-consultation for patients with suspicion for and/or confirmed HIT can improve adherence to guidelines and improve care outcomes.