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Increasing optimal coagulation factor dosing in the paediatric emergency department: Update to a quality improvement
Nicole E Kendel1,2, Eman Abdelghani1, Joseph R Stanek1,3
1Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA.
Insights
Improving factor dosing for haemophilia patients in the emergency department remains a challenge. While interventions reduced out-of-range dosing from 33.3% to 18%, further efforts are needed for optimal patient care.
Area of Science:
- Pediatric Emergency Medicine
- Hematology
- Quality Improvement Science
Background:
- Prompt and accurate coagulation factor replacement is crucial for managing injuries and bleeding in individuals with haemophilia (HA) and haemophilia B (HB).
- Inappropriate dosing can lead to acute and long-term complications, necessitating optimized treatment protocols.
Purpose of the Study:
- To increase the proportion of appropriately treated HA and HB patients in a pediatric emergency department from 65% to 85%.
- To reduce the incidence of out-of-range coagulation factor dosing during emergency department encounters.
- To increase the time interval between patient encounters with incorrect factor dosing.
Main Methods:
- Quality improvement methodology, including plan-do-study-analyze cycles, was employed.
- Audits of emergency department encounters assessed coagulation factor dosing for HA/HB patients.
- Interventions focused on improving communication through the electronic medical record and enhancing physician education.
Main Results:
- The rate of out-of-range factor dosing in emergency department encounters decreased from 33.3% to 18% after interventions.
- The mean percentage of encounters receiving optimal factor dosing (82.2%) showed an increase compared to baseline (71.1%), although not statistically significant.
- Despite improvements, out-of-range dosing still occurred in a notable proportion of cases.
Conclusions:
- Multiple interventions did not fully eliminate out-of-range factor dosing in the emergency department.
- Future plans include reinstating simulation center education and continuing educational efforts for healthcare professionals.
- The goal is to further minimize dosing errors and improve patient outcomes in emergency settings.
Introduction:
Prompt, appropriate coagulation factor replacement according to injury and bleeding severity in persons with haemophilia is required to prevent acute and long-term complications.
Aims:
Increase proportion of persons with haemophilia A (HA) and B (HB) treated appropriately for an acute injury and bleeding episode at a tertiary children's emergency department (ED) from 65% to 85% and sustain for one year. Secondary aim: increase time interval between patient ED encounters with out-of-range factor dosing.
Methods:
Utilizing quality improvement methodology and plan-do-study-analyze cycles, ED encounters for individuals with HA/HB receiving coagulation factor replacement for injuries were audited for in-range coagulation factor dosing. Goal factor dose defined as 50% correction for minor bleeds and 100% correction for major bleeds. Optimal dosing range defined as 90%-120% of the calculated goal dose to account for vial size variability. Interventions targeted communication via the EMR problem list and optimization of physician education.
Results:
Our previous publication demonstrated 33.3% of ED encounters with out-of-range factor replacement. Following several interventions, the cumulative rate of encounters with out-of-range dosing decreased to 18%. Overall, there was an increase in the mean percent of encounters receiving optimal factor dosing for both HA/HB compared to baseline (82.2% vs. 71.1%), though this was not a statistically significant difference.
Conclusion:
Despite implementation of multiple interventions, out-of-range factor dosing continues to occur. Our team plans to reinstate simulation center education for ED staff and continue education efforts of pharmacists and hematology trainees with the goal of further reducing out-of-range dosing in our ED.
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