Clinical Care Guideline Implementation of Nebulized Tranexamic Acid in Post-Tonsillectomy Hemorrhage

Nebulized tranexamic acid (TXA) can be utilized for non-operative management in post-tonsillectomy hemorrhage (PTH). Rapid adoption of new treatments in hospital settings is challenging due to personnel turnover, formulary restrictions, and inconsistent awareness. We investigated the utility of clinical care guideline (CCG) implementation on adherence to a TXA protocol and its association with operative control of hemorrhage.

Model for Improvement methodology was utilized to develop CCG for TXA administration. An algorithm was created where patients presenting to the Emergency Department (ED) with active bleeding or blood clot received three nebulized TXA treatments. Exclusion criteria were severe bleeding, absence of active bleeding or clot, and inability to tolerate treatment or protect the airway. An order set was used to facilitate implementation. Data from 2 years pre- and post-initiation were compared. Measures included ED returns for PTH, TXA order set usage, TXA administration frequency, returns to the operating room, and secondary returns to the ED.

There were 2805 and 5382 tonsillectomies pre- and post- implementation periods respectively. There was no difference in patient age in the two groups. ED returns for bleeding were 70 (2.5%) and 155 (2.9%) respectively (p > 0.05). Post-implementation, 126 patients met inclusion criteria for TXA (81.3%). Order set utilization of patients receiving TXA in the ED was 95.7%. Operative PTH management pre- and post-intervention was 35/70 (50%) and 42/155 (27.1%) respectively (p = 0.001, ARR 0.320, 95% CI 0.116-0.500).

Implementation of a PTH clinical care guideline was associated with rapid adoption of TXA adherence. This was associated with reduced rates of OR returns.