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A Quality Improvement Bundle to Improve Informed Choice for Children With Typical, Newly Diagnosed Immune Thrombocytopenia

Beck, Carolyn E., MSc, MD, FRCPC*,†,‡; Carcao, Manuel, MSc, MD, FRCPC‡,§; Cada, Michaela, MD, FRCPC‡,§; Porter, Stephen, MD, FAAP; Blanchette, Victor S., MD, FRCPC‡,§; Parkin, Patricia C., MD, FRCPC*,†,‡

Journal of Pediatric Hematology/Oncology: November 2018 - Volume 40 - Issue 8 - p e537–e543
doi: 10.1097/MPH.0000000000001247
Online Articles: Original Articles

IVIG has been the predominant therapy for the initial management of children with newly diagnosed immune thrombocytopenia at our hospital. With current guidelines supporting more conservative management, we undertook a quality improvement initiative to lead practice change. Over a 2-year time period (2013 to 2015), we strove to decrease use of hospital resources (use of IVIG, length of stay) while optimizing family satisfaction. An interdisciplinary working group was struck and a quality improvement bundle was implemented. The bundle comprised a patient information sheet; an evidence-informed, consensus-based protocol; and promotion of shared decision-making via stakeholder engagement and education. Data were collected prospectively; baseline data from a 2007 to 2009 audit were used for comparison. In total, 27 patients were included. Mean initial platelet count was 4×109/L. Bleeding was classified as none or mild in 56% of patients. IVIG use decreased from 88% to 55% of patients, corticosteroid prescription increased from 6% to 15%, and observation increased from 6% to 30% of patients. Hospital length of stay decreased from 47 to 36 hours. Family satisfaction was stable across treatment groups. Through introduction of a quality improvement initiative, we were able to improve family-centered care and decrease use of hospital resources.

*Division of Pediatric Medicine

Pediatric Outcomes Research Team

§Division of Hematology/Oncology

Department of Pediatrics and Research Institute, Hospital for Sick Children, Toronto and the University of Toronto, Toronto, ON, Canada

Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

A Creative Professional Activity Grant from The Hospital for Sick Children’s Department of Pediatrics funded this study. The Pediatric Outcomes Research Team (PORT) is supported by a grant from the Hospital for Sick Children Foundation.

M.C. has received research funding from Baxalta (now Shire) and Octapharma. He has also received honoraria for speaking at industry-sponsored symposia from Baxalta (Shire), Grifols and Octapharma, all manufacturers of IVIG. V.S.B. is Chair of the International Prophylaxis Study Group (IPSG), a not for profit collaborative study group whose mission is to facilitate the acquisition of new knowledge regarding regular replacement therapy (prophylaxis) with clotting factor concentrates in persons with inherited bleeding disorders, and the dissemination of this knowledge globally. The IPSG is supported by grants from Bayer Healthcare, Baxalta, Biogen Idec, CSL-Behring, Novo Nordisk, and Pfizer to the Hospital for Sick Children Foundation, Toronto, Canada. V.S.B. does not receive any personal remuneration for his role as Chair of the IPSG. He has received speaker fees and fees for participation in Advisory Boards from Amgen, Bayer Healthcare, Baxalta, Biogen Idec, Novo Nordisk, and Pfizer. V.S.B. is a coprincipal investigator for an investigator initiated, industry supported (Baxalta) research grant and also a member of a Data Safety Monitoring Board for Octapharma. P.C.P. is the principal investigator for an investigator-initiated trial of iron deficiency in young children funded by Canadian Institutes of Health Research (FRN #115059); Mead Johnson Nutrition supplies Fer-In-Sol in-kind for this trial. P.C.P. receives funds from the Hospital for Sick Children to support the research activities of the Pediatric Outcomes Research Team (PORT). The remaining authors declare no conflict of interest.

Reprints: Carolyn E. Beck MSc, MD, FRCPC, Division of Pediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada M5G 1X8 (e-mail:

Received December 5, 2017

Accepted May 11, 2018

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