A quality improvement project for managing hypocalcemia after pediatric total thyroidectomy

Area of Science:

• Pediatric Endocrinology
• Surgical Outcomes
• Quality Improvement

Background:

• Hypocalcemia is a common complication after total thyroidectomy (TT), leading to increased morbidity and healthcare costs.
• Current management guidelines for pediatric patients undergoing TT are lacking, particularly regarding intravenous (IV) calcium gluconate use.
• IV calcium gluconate treatment carries potential risks, necessitating a refined approach to its administration.

Purpose of the Study:

• To develop and implement a clinical pathway for pediatric total thyroidectomy patients.
• To decrease the utilization of IV calcium gluconate from a baseline of 68% to under 40%.
• To reduce the incidence of hypocalcemia and shorten hospitalization duration post-TT.

Main Methods:

• A Quality Improvement (QI) project was initiated at Phoenix Children's Hospital, involving pediatric endocrinologists, surgeons, and otolaryngologists.
• Interventions included pre-operative calcium supplementation, electronic health record pathway integration, and regular pathway reminder emails.
• The study tracked IV calcium gluconate use, hypocalcemia rates, and length of hospital stay in 27 pediatric patients over 15 months.

Main Results:

• IV calcium gluconate use decreased from 68% to 48%, falling short of the 40% target.
• Hypocalcemia occurred in 96% of patients, with an average hospital stay of 52.7 hours.
• Post-operative parathyroid hormone (PTH) nadir below 15 pg/mL was strongly associated with the need for IV calcium (73% vs. 17%).

Conclusions:

• Standardizing care through a clinical pathway facilitates objective outcome analysis in pediatric TT.
• Post-operative serum PTH levels are a key predictor for requiring IV calcium gluconate.
• The QI pathway allows for iterative improvements to optimize patient care and resource utilization in pediatric thyroid surgery.