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Pediatric mediastinal mass algorithm: A quality improvement initiative to reduce time from presentation to biopsy
Jamie M Fleming1, Savannah Ross1, Lindsey M Hoffman2
1Anschutz Medical Center, University of Colorado Denver, Aurora, CO, USA.
Insights
Implementing a standardized algorithm significantly reduced diagnostic times for pediatric anterior mediastinal masses. This quality improvement initiative expedited biopsies and may decrease the need for emergency pretreatment.
Area of Science:
- Pediatric Oncology
- Thoracic Surgery
- Quality Improvement Science
Background:
- Mediastinal masses in children can cause critical airway and great vessel compression.
- Variable care pathways may delay diagnosis and complicate treatment, increasing risks.
- Standardized care and expedited diagnosis are crucial for patient safety and outcomes.
Purpose of the Study:
- To decrease the time from presentation to diagnostic biopsy for pediatric anterior mediastinal masses by 50% over three years.
- To improve the standardization of care for children with mediastinal masses.
- To reduce the utilization of emergency pretreatment in this patient population.
Main Methods:
- A quality improvement project at a tertiary healthcare center involving 71 patients (2008-2018).
- Utilized the Model for Improvement framework, including a driver diagram and Plan-Do-Study-Act (PDSA) cycles.
- Implemented a multidisciplinary algorithm to standardize initial care and communication, analyzing time to biopsy and pretreatment rates.
Main Results:
- Time from presentation to biopsy significantly decreased from 48 hours at baseline to 24 hours post-implementation.
- The proportion of patients receiving emergency pretreatment decreased from 26.3% to 6.7%, though not statistically significant.
- Analysis included 19 patients preintervention and 52 patients postintervention.
Conclusions:
- A coordinated, multidisciplinary algorithm significantly reduced diagnostic delays for pediatric mediastinal masses.
- This standardized approach may lead to a reduction in the use of emergent pretreatment.
- Expediting diagnosis and management improves acute patient safety and long-term outcomes.
Background:
Mediastinal masses in children may present with compression of the great vessels and airway. An interdisciplinary plan for rapid diagnosis, acute management, and treatment prevents devastating outcomes and optimizes care. Emergency pretreatment with steroids or radiation is more likely to be administered when care is variable, which may delay and complicate diagnosis and treatment. Strategies to standardize care and expedite diagnosis may improve acute patient safety and long-term outcomes.
Aims:
The aim of this quality improvement project was to decrease time from presentation to diagnostic biopsy for children with an anterior mediastinal mass by 50% over 3 years within a tertiary healthcare system.
Methods:
This quality improvement project involved a single center with data collected and analyzed retrospectively and prospectively for 71 patients presenting with anterior mediastinal mass between February 2008 and January 2018. The Model for Improvement was utilized for project design and development of a driver diagram and smart aim. An algorithm was implemented to facilitate communication between teams and standardize initial care of patients with mediastinal masses. The algorithm underwent multiple Plan-Do-Study-Act (PDSA) cycles. Data were collected before and after algorithm implementation and between each PDSA cycle. The primary outcome measure included time from presentation to biopsy, which was monitored with a statistical process control chart. Several process measures were evaluated with Student's t-tests including administration of emergency pretreatment.
Results:
Nineteen patients preintervention and 52 patients postintervention were included in the analysis. Time from presentation to biopsy significantly decreased from 48 h at baseline to 24 h postimplementation. Although not statistically significant, emergency pretreatment decreased from a baseline of 26.3% to 6.7% postimplementation.
Conclusion:
Implementation of a diagnostic and management algorithm coordinating care among multidisciplinary teams significantly reduced time to biopsy for children presenting with mediastinal mass and may result in decreased use of emergent pretreatment.
