Standardizing the evaluation and management of iron deficiency anemia secondary to heavy menstrual bleeding in the emergency department.

BACKGROUND: Comprehensive guidelines for the management of iron deficiency anemia (IDA) in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize the evaluation and management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology. METHODS: Baseline data of the target population identified variability across four key measures of clinical management: therapy choice and administration, laboratory evaluation, hematology service consultation, and patient disposition. Literature review and consensus from pediatric hematology and gynecology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From December 2022 to July 2023, we aimed to achieve a 25% relative increase in patients to receive optimal management per the algorithm, while using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider documentation and balancing measures, such as ED length of stay, were assessed concurrently. RESULTS: Forty-nine patients were evaluated during four PDSA cycles. Improvement of ≥40% above baseline regarding recommended therapy administration was achieved across four PDSA cycles. Adherence to recommended therapy choice improved from 57% (baseline) to 100%, minimal laboratory evaluation from 14% to 83%, hematology consultation from 36% to 100%, and appropriate disposition from 71% to 100%. ED length of stay remained stable. CONCLUSION: Implementation of a standardized algorithm for management of IDA secondary to HMB in adolescents in the ED increased adherence to evidence-based patient care.

Transcranial Doppler Screening Adherence among Children with Sickle Cell Anemia Seen in the Emergency Department.

OBJECTIVE: To evaluate adherence to annual transcranial Doppler ultrasound (TCD) screening to prevent stroke among patients with sickle cell anemia (SCA) seen in the emergency department (ED). STUDY DESIGN: This retrospective chart review included patients with SCA seen at a large pediatric ED over 64 weeks. Patients who did not need a TCD (age <2 or ≥16 years, on chronic transfusions, history of an inadequate TCD) or were not followed at the study institution were excluded. Patients who had received a TCD in the last 12 months (TCD adherent) were compared with patients who had not (TCD nonadherent). RESULTS: During the study period, 257 patients with SCA in need of an annual TCD were identified and 63 patients (25%) had not received an annual TCD, including 19 patients (7%) who had never had a TCD. All TCD adherent patients had a clinic visit in the last year compared with 75% of TCD nonadherent patients, P < .0001. The mean interval time since the last hematology clinic appointment from the ED encounter was greater for the TCD nonadherent group: 70 vs 270 days, P < .0001. Demographics including markers of socioeconomic status were not significantly different between the 2 groups. CONCLUSIONS: Patients with SCA who present to the ED and are nonadherent to TCD screening guidelines are less likely to have had a recent hematology clinic visit. Future interventions to improve screening for stroke in SCA should target this patient population seen in the ED but not clinic.

Inpatient Ordering of Home Hydroxyurea by Residents for Hospitalized Patients With Sickle Cell Disease.

BACKGROUND: Hydroxyurea is a well-established disease-modifying medication for sickle cell disease (SCD). At some institutions, hydroxyurea can only be ordered by "chemotherapy-certified" providers which may not include pediatric resident physicians. METHODS: We conducted a survey of 39 American pediatric hospitals regarding their policy on resident hydroxyurea ordering for SCD. Our institution changed its policy in June 2016 to allow residents to order hydroxyurea for hospitalized patients with SCD who were already on hydroxyurea at home. We conducted a retrospective review of the medical records of a random sample of patients with SCD on hydroxyurea admitted the year before and the year after this policy change. RESULTS: In our national survey, 51% of surveyed hospitals allowed residents to order hydroxyurea, 19% required a second signature, and 30% did not allow residents to order hydroxyurea. In our institutional study, patients after the policy change were significantly more likely to have received their home hydroxyurea by hospital day 1: before 62/90 (69%) versus after 105/119 (88%), P=0.0005. The proportion of patients who inappropriately received hydroxyurea was very low in both groups: before 1/91 (1%) versus after 3/126 (2%), P=0.64, with no serious adverse clinical events due to inappropriate hydroxyurea administration. CONCLUSIONS: Considerable national variation in practice currently exists in regards to resident hydroxyurea ordering hospital policies. A policy allowing residents to order hydroxyurea significantly increased the likelihood of a patient receiving hydroxyurea while hospitalized with no significant increase in inappropriate hydroxyurea administration. Resident hydroxyurea ordering seems safe and beneficial.

Targeted Hydroxyurea Education after an Emergency Department Visit Increases Hydroxyurea Use in Children with Sickle Cell Anemia.

OBJECTIVE: To evaluate the impact of an initiative to increase hydroxyurea use among children with sickle cell anemia (SCA) who presented to the emergency department (ED). STUDY DESIGN: This observational cohort study included children with SCA not taking hydroxyurea who presented to the ED with pain or acute chest syndrome and then attended a Quick-Start Hydroxyurea Initiation Project (Q-SHIP) session. A Q-SHIP session includes a hematologist-led discussion on hydroxyurea, a video of patients talking about hydroxyurea, and a direct offer to start hydroxyurea. RESULTS: Over 64 weeks, 112 eligible patients presented to the ED and 59% (n = 66) participated in a Q-SHIP session a median of 6 days (IQR 2, 20 days) after ED or hospital discharge; 55% of participants (n = 36) started hydroxyurea. After a median follow-up of 49 weeks, 83% (n = 30) of these participants continued hydroxyurea. Laboratory markers of hydroxyurea adherence were significantly increased from baseline: median mean corpuscular volume +8.6 fL (IQR 5.0, 17.7, P < .0001) and median hemoglobin F +5.7% (IQR 2.5, 9.8, P = .0001). Comparing Q-SHIP participants to nonparticipants, 12 weeks after ED visit, participants were more likely to have started hydroxyurea than nonparticipants (53% vs 20%, P = .0004) and to be taking hydroxyurea at last follow-up (50% vs 20%, P = .001). Two years after the implementation of Q-SHIP the overall proportion of eligible patients on hydroxyurea presenting to our ED increased from 56% to 80%, P = .0069. CONCLUSIONS: Participation in a clinic to specifically address starting hydroxyurea after a SCA complication increases hydroxyurea use.

A brief survey of health habits among childhood cancer survivors.

Using a survey, we assessed four health habits in 468 pediatric cancer survivors. Approximately 75% were at goal for ≥1 behavior-44% were active ≥1 hr per day, 40% engaged in ≤1 hr of screen time a day, 34% consumed sweetened beverages not often, and 4% ate >4 servings of fruits and vegetables per day. Survivors' age was associated with being active (P < 0.001) and limited screen time (P = 0.001). Males were more likely to be active (P = 0.003). The most common combination of goal behaviors was activity and screen time. Encouraging healthy behaviors may decrease the burden of late effects in survivors.