Each year, the American Society of Hematology (ASH) recognizes the efforts of practitioners who have implemented intervention-based projects that focus on improving the quality of care delivered in their practice, institution, or hospital system. Newly rebranded for 2024 as the Quality Improvement Champions, this initiative combines and replaces the retired Choosing Wisely Champions and Guideline Implementation Champions programs, with expanded opportunities for clinicians to tackle any quality improvement-related project, rather than only those aimed at preventing overuse or implementing guideline recommendations.
The 2024 Champions will present their projects and findings at the 66th ASH Annual Meeting and Exposition in San Diego from December 7-10. Read on to learn more about these individuals, their projects, and what you can expect at the annual meeting’s Quality Improvement Champions session.
Management of Iron Deficiency in Adolescents with Heavy Menstrual Bleeding
Josie Fernandez Sanchez, MD
With few comprehensive guidelines for managing iron deficiency anemia in adolescents with heavy menstrual bleeding (HMB) who present to the emergency department (ED), Josie Fernandez Sanchez, MD, of Texas Children’s Hospital and Baylor College of Medicine, and her colleagues observed that the care of this population often varies widely. For example, a 2020 study found that out of 258 adolescents who presented to the ED with HMB, only 23 patients (8.9%) had iron studies performed, and 18 of those 23 patients (78.3%) had iron deficiency, and 21 of 23 (92.3%) were anemic, indicating that those at significant risk of iron deficiency are not being adequately screened or treated.1 Dr. Fernandez Sanchez and her colleagues sought to standardize the evaluation process for such patients at Texas Children’s Hospital and improve the quality of care they receive.
Their project involved multidisciplinary efforts between four divisions at Texas Children’s Hospital (Pediatric Hematology, Pediatric and Adolescent Gynecology, Pediatric Emergency Medicine, and Pediatric Hospital Medicine) and led to the creation and implementation of an evidence-based algorithm for the evaluation and management of this young patient population.
“Undertaking this project gave our team a deeper insight into how our systems function and highlighted the value of practicing medicine through a multidisciplinary approach,” Dr. Fernandez Sanchez said.
Throughout the project, the team encountered various barriers to the algorithm’s implementation and consequently developed strategies to improve adherence.
“We faced several challenges, the most significant being the high turnover of providers in a large academic center,” Dr. Fernandez Sanchez said. “To address this, we implemented ongoing education sessions and distributed printed materials in key work areas to maintain awareness of our algorithm.”
Following the algorithm’s implementation, adherence to the recommended therapy choice significantly improved from a baseline of 57% to 100%. The team also saw increases in hematology consultations (36% to 100%) and appropriate patient disposition (71% to 100%).2
“I hope other teams will consider adopting our approach and implementing similar algorithms to standardize care for this patient population across EDs,” Dr. Fernandez Sanchez said. “It’s important for providers to recognize that multidisciplinary collaboration can lead to significant improvements in outcomes within a shorter timeframe through quality improvement initiatives.”
Administration of Blood Products Pre-Paracentesis in Chronic Liver Disease
Paolo Lopedote, MD
For Paolo Lopedote, MD, then of St. Elizabeth’s Medical Center in Boston, and his colleagues, a session at the 2023 ASH annual meeting sparked their desire to improve patient care at their institution. The session, chaired by Lara Roberts, MD, MBBS, of King’s College Hospital, summarized the literature on hemostasis in patients with chronic liver disease (CLD) and endorsed major guidelines advising against fresh frozen plasma (FFP) and platelet transfusions before low-bleeding-risk procedures, such as paracentesis.3
Following this session, Dr. Lopedote and colleagues realized that 73% of patients with CLD at their institution received FFP or platelet transfusions before paracentesis if they had abnormal international normalized ratios (INR) or platelet counts, contrary to what guidelines advise. They then decided to undertake a quality improvement initiative with the goal of identifying the underlying systemic factors for this discrepancy and increasing compliance with evidence-based guidelines.
“Low-bleeding-risk procedures such as paracentesis should not be delayed for abnormalities in the INR or platelet count in patients with CLD, and we probably need better and [more] accessible tools to evaluate the coagulation profile of these patients,” said Dr. Lopedote, a current fellow at City of Hope National Medical Center.
To carry out this project, a task force comprising residents, a hospitalist, and two interventional radiologists was formed, and educational flyers were distributed in key areas of the hospital to address underlying knowledge gaps and misconceptions.
Over ten months, the team observed a 75% reduction in the rate of FFP or platelet transfusions administered to patients with CLD prior to paracentesis. Dr. Lopedote credited this significant outcome to the collaborative nature of the project, saying, “Teaming up with the departments that performed the majority of paracenteses in our institution (i.e., interventional radiology and critical care) was key to the success of our initiative.”
Recognition and Management of Hemophilia in the ED
Asinamai Ndai, BPharm, MS
The National Bleeding Disorders Foundation’s Medical and Scientific Advisory Council (MASAC) recommends that patients with hemophilia presenting to the ED with bleeding receive factor replacement therapy (FRT) within one hour of arrival.4 Asinamai Ndai, BPharm, MS, and his colleagues, however, noticed that patients coming to the ED at University of Florida Health were experiencing delays in FRT administration, which, as noted in the MASAC guidelines, can significantly affect patient morbidity and mortality.
Seeking to reduce the time to FRT administration among patients in the ED, Dr. Ndai and colleagues developed a continuous quality improvement initiative. This initiative involved training ED physicians on hemophilia guidelines, creating a specialized medication order set within the electronic medical record (EMR), and implementing a rapid triage system.
To measure efficacy, the team compared the time between a patient’s arrival in the ED and FRT administration before and after the initiative’s implementation. In total, 43 ED visits were recorded, and the team found that the average time from arrival to FRT administration decreased by nearly 44% from 5.63 hours to 3.15 hours.
A key strategy that led to the project’s successful outcomes was the use of advanced analytics and integrating guidance and management strategies directly into the EMR, which Dr. Ndai noted was especially helpful when working with a rare disease like hemophilia.
“Our analytics tools enabled detailed data visualization and allowed for the ‘slicing and dicing’ of limited data to extract powerful insights from small datasets,” he said. “This allowed for continuous iteration based on feedback from practice, which could be monitored and reported through EMR usage.”
Learn More at the ASH Annual Meeting
To hear more about this year’s Quality Improvement Champions and their projects, be sure to attend the “ASH Quality Improvement Champions” Special Interest Session at the ASH annual meeting this December. Visit hematology.org/meetings/annual-meeting/schedule-and-program/programs to access the session date and time.
Presenters will discuss the unique barriers and challenges they faced when developing and implementing their projects and how they overcame them, the collaborative nature of their projects, and the impact and outcomes of their initiatives.
“I hope attendees leave this session inspired and equipped with practical strategies they can adapt and implement in their own institutions, always keeping the patient’s well-being at the forefront,” Dr. Ndai said. “Quality improvement is not just about hitting benchmarks; it’s about making clinically meaningful difference in patients’ lives.”
References
- Stoffers VL, Weyand AC, Quint EH, et al. Assessment of iron status in adolescents presenting to the emergency department with heavy menstrual bleeding. Pediatric Emergency Care. 200;38(5):e1266-e1270.
- Fernandez Sanchez J, Sánchez LM, Kappa SS, et al. Standardizing the evaluation and management of iron deficiency anemia secondary to heavy menstrual bleeding in the emergency department. Pediatr Blood Cancer. 2024;e
- Roberts, LN. Hemostasis in patients with severe liver disease. Presented at the 65th American Society of Hematology Annual Meeting and Exposition; December 10, 2023; San Diego, California.
- National Bleeding Disorders Foundation. MASAC document 257 - guidelines for emergency department management of individuals with hemophilia and other bleeding disorders. December 5, 2019. Accessed August 20, 2024. https://www.bleeding.org/healthcare-professionals/guidelines-on-care/masac-documents/masac-document-257-guidelines-for-emergency-department-management-of-individuals-with-hemophilia-and-other-bleeding-disorders.
