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Implementation of a Process for Initial Transcranial Doppler Ultrasonography in Children With Sickle Cell Anemia
Lori E Crosby1, Naomi E Joffe1, Blair Davis2
1Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; College of Medicine, University of Cincinnati, Cincinnati, Ohio.
Insights
Quality improvement methods increased Transcranial Doppler ultrasonography (TCD) screening for children with sickle cell anemia (SCA). This initiative successfully screened 100% of eligible patients, significantly improving early stroke risk detection.
Area of Science:
- Pediatric Neurology
- Hematology
- Quality Improvement Science
Background:
- Stroke is a severe complication of sickle cell anemia (SCA), leading to permanent neurological deficits.
- Transcranial Doppler ultrasonography (TCD) is crucial for identifying children with SCA at high risk of stroke.
- Current TCD screening rates in young children with SCA fall below recommended guidelines.
Purpose of the Study:
- To implement quality improvement (QI) methods to increase the rate of initial TCD screening in SCA patients aged 24-27 months.
- The project aimed to improve the successful TCD completion rate from 25% to 75% by December 31, 2013.
Main Methods:
- Utilized QI methodologies including process mapping, failure mode and effects analysis, and plan-do-study-act cycles.
- Developed and tested processes for patient identification, TCD scheduling, pre-procedure preparation, and outcome monitoring.
- Tracked progress using patient eligibility reports and a population metric of the age at first successful TCD.
Main Results:
- Achieved 100% successful initial TCD screening for all eligible patients by December 2013, maintaining this rate for 20 months.
- Statistical analysis (Welch's one-way ANOVA) revealed a significant difference in the average age of first TCD between pre-intervention (2009) and intervention (2010-2013) cohorts (p=0.002).
Conclusions:
- Implementing a TCD protocol using QI methods significantly improved screening rates in young children with SCA.
- This approach effectively enhanced early detection of stroke risk in this vulnerable pediatric population.
- Sustained high screening rates demonstrate the long-term impact of systematic QI interventions.
Abstract:
Stroke, a devastating complication of sickle cell anemia (SCA), can cause irreversible brain injury with physical and cognitive deficits. Transcranial Doppler ultrasonography (TCD) is a non-invasive tool for identifying children with SCA at highest risk of stroke. National guidelines recommend that TCD screening begin at age 2 years, yet there is research to suggest less than half of young children undergo screening. The purpose of this project was to use quality improvement methods to improve the proportion of patients aged 24-27 months who successfully completed their initial TCD from 25% to 75% by December 31, 2013. Quality improvement methods (e.g., process mapping, simplified failure mode effect analysis, and plan-do-study-act cycles) were used to develop and test processes for identifying eligible patients, scheduling TCDs, preparing children and families for the first TCD, and monitoring outcomes (i.e., TCD protocol). Progress was tracked using a report of eligible patients and a chart showing the age in months for the first successful TCD (population metric). As of December 2013, 100% of eligible patients successfully completed their initial TCD screen; this improvement was maintained for the next 20 months. In November 2014, a Welch's one-way ANOVA was conducted. Results showed a statistically significant difference between the average age of first TCD for eligible patients born in 2009 and eligible patients born during the intervention period (2010-2013; F[1,11.712]=16.03, p=0.002). Use of quality improvement methods to implement a TCD protocol was associated with improved TCD screening rates in young children with SCA.
