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Reduction in Systolic Hypertension in Children Undergoing Hematopoietic Stem Cell Transplantation
S280
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
406 Reduction in Systolic Hypertension in Children Undergoing Hematopoietic Stem Cell Transplantation Adam S. Nelson 1, Michelle Lewyckyj 2, Laura Flesch 1, Kathleen Novak 3, Kathleen Marie Demmel 4, Ashley Teusink 5, Sonata Jodele 1, Stella M. Davies 1, Christopher E. Dandoy 1. 1 Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2 BMT, Cincinnat Children’s Hospital Medical Center, Cincinnati, OH; 3 Cancer and Blood Diseases Institute Blood and Marrow Transplant, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, OH; 5 Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Topic Significance & Study Purpose/Background/ Rationale: Children undergoing HSCT are at risk of significant morbidity and mortality from untreated or unrecognized hypertension. Analysis of our inpatient BMT unit revealed nearly 50% of all blood pressures recorded on a daily basis were above the 95th percentile for blood pressure norms. The aim of this project was to reduce the percentage of systolic blood pressures recorded >95th centile from 50% to 20% by October 2015 using the Model for Improvement. Methods, Intervention, & Analysis: Through Pareto analysis and Failure Mode Effects Analysis (FMEA), we identified variables associated with failure to recognize hypertension and a time-lag between identifying hypertension and instituting appropriate treatment. Pareto followed by FMEA analysis revealed lack of knowledge regarding normal values, inefficient BP measuring procedures, lack of administration of appropriate medications and failure to identify patients at risk of hypertension as likely causes of persistent systolic hypertension. From these findings, we created our key drivers (Fig 1) and through small tests of change developed a standardized process consisting of: 1) entering correct and verified BP parameters for all inpatients, 2) standardizing a protocol for checking patient’s blood pressure, 3) empowering nursing staff to assess and treat hypertension within a timely manner. We monitored the process by reviewing all blood pressures recorded on a daily basis and comparing these to BP norms. Findings & Interpretation: After implementing a standardized process for measuring and entering appropriate BP ranges into the medical record of each patient, as well as empowering nursing staff to accurately assess and treat
Figure 1.
Figure 2.
patients with hypertension, we saw a decrease in the percentage of patients who had a systolic blood pressure >95th centile from 50% to 25%. There were no episodes of hypotension or escalation of medical care associated with hypotension. Discussion & Implications: Implementation of a standardized process for hypertension recognition, measurement and treatment of systolic hypertension in children undergoing HSCT has resulted in a reduction in percentage of BPs recorded on a daily basis breaching the 95th percentile.
407 Red Blood Cell Transfusions: Tried and True or Something New? Penny Odem 1, Sharon Kelly 2. 1 Quality Management Supervisor, Colorado Blood Cancer Institute at P/SL, Denver, CO; 2 Blood Bank Medical Director, Presbyterian St. Luke’s Medical Center, Denver, CO Problem: Red blood cell (RBC) transfusions can be lifesaving. Yet data demonstrate association between transfusions and risk of infection, iron overload, thrombosis, multi-organ failure and increased mortality. Transfusions expose patients to donor antigens which lead to RBC alloimmunization increasing risk of hemolytic reactions and limiting availability of compatible products as time goes on. Data are published regarding the safety and efficacy of changing transfusion parameters to a hemoglobin <7 g/dl and moving towards single unit transfusions. However, very little of these data are directed towards hematology and more specifically the stem cell transplant population. Intervention: In January of 2015, an algorithm was developed to more judiciously transfuse transplant patients. RBC transfusion triggers were modified to a hemoglobin < 7 g/dl. Patients meeting this value received 2 units of PRBC’s from start of preparative regimen through Day +9, and after Day +9, only one unit was transfused if parameter was met. Medical records of 149 inpatient BMT patients (89 autologous and 60 allogeneic) were retrospectively reviewed for hemoglobin results and RBC transfusions. A total of 109 records were eligible for in depth review. Patients were excluded if their hemoglobin never dropped below 8 g/dl, they received multiple blood component transfusions over a short period of time causing potential for the data to be skewed, or if deemed medically necessary that the algorithm not be followed. Results: Analysis of the data showed that use of the new algorithm for inpatient RBC transfusions over a period of 8
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
406 Reduction in Systolic Hypertension in Children Undergoing Hematopoietic Stem Cell Transplantation Adam S. Nelson 1, Michelle Lewyckyj 2, Laura Flesch 1, Kathleen Novak 3, Kathleen Marie Demmel 4, Ashley Teusink 5, Sonata Jodele 1, Stella M. Davies 1, Christopher E. Dandoy 1. 1 Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2 BMT, Cincinnat Children’s Hospital Medical Center, Cincinnati, OH; 3 Cancer and Blood Diseases Institute Blood and Marrow Transplant, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4 Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, OH; 5 Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH Topic Significance & Study Purpose/Background/ Rationale: Children undergoing HSCT are at risk of significant morbidity and mortality from untreated or unrecognized hypertension. Analysis of our inpatient BMT unit revealed nearly 50% of all blood pressures recorded on a daily basis were above the 95th percentile for blood pressure norms. The aim of this project was to reduce the percentage of systolic blood pressures recorded >95th centile from 50% to 20% by October 2015 using the Model for Improvement. Methods, Intervention, & Analysis: Through Pareto analysis and Failure Mode Effects Analysis (FMEA), we identified variables associated with failure to recognize hypertension and a time-lag between identifying hypertension and instituting appropriate treatment. Pareto followed by FMEA analysis revealed lack of knowledge regarding normal values, inefficient BP measuring procedures, lack of administration of appropriate medications and failure to identify patients at risk of hypertension as likely causes of persistent systolic hypertension. From these findings, we created our key drivers (Fig 1) and through small tests of change developed a standardized process consisting of: 1) entering correct and verified BP parameters for all inpatients, 2) standardizing a protocol for checking patient’s blood pressure, 3) empowering nursing staff to assess and treat hypertension within a timely manner. We monitored the process by reviewing all blood pressures recorded on a daily basis and comparing these to BP norms. Findings & Interpretation: After implementing a standardized process for measuring and entering appropriate BP ranges into the medical record of each patient, as well as empowering nursing staff to accurately assess and treat
Figure 1.
Figure 2.
patients with hypertension, we saw a decrease in the percentage of patients who had a systolic blood pressure >95th centile from 50% to 25%. There were no episodes of hypotension or escalation of medical care associated with hypotension. Discussion & Implications: Implementation of a standardized process for hypertension recognition, measurement and treatment of systolic hypertension in children undergoing HSCT has resulted in a reduction in percentage of BPs recorded on a daily basis breaching the 95th percentile.
407 Red Blood Cell Transfusions: Tried and True or Something New? Penny Odem 1, Sharon Kelly 2. 1 Quality Management Supervisor, Colorado Blood Cancer Institute at P/SL, Denver, CO; 2 Blood Bank Medical Director, Presbyterian St. Luke’s Medical Center, Denver, CO Problem: Red blood cell (RBC) transfusions can be lifesaving. Yet data demonstrate association between transfusions and risk of infection, iron overload, thrombosis, multi-organ failure and increased mortality. Transfusions expose patients to donor antigens which lead to RBC alloimmunization increasing risk of hemolytic reactions and limiting availability of compatible products as time goes on. Data are published regarding the safety and efficacy of changing transfusion parameters to a hemoglobin <7 g/dl and moving towards single unit transfusions. However, very little of these data are directed towards hematology and more specifically the stem cell transplant population. Intervention: In January of 2015, an algorithm was developed to more judiciously transfuse transplant patients. RBC transfusion triggers were modified to a hemoglobin < 7 g/dl. Patients meeting this value received 2 units of PRBC’s from start of preparative regimen through Day +9, and after Day +9, only one unit was transfused if parameter was met. Medical records of 149 inpatient BMT patients (89 autologous and 60 allogeneic) were retrospectively reviewed for hemoglobin results and RBC transfusions. A total of 109 records were eligible for in depth review. Patients were excluded if their hemoglobin never dropped below 8 g/dl, they received multiple blood component transfusions over a short period of time causing potential for the data to be skewed, or if deemed medically necessary that the algorithm not be followed. Results: Analysis of the data showed that use of the new algorithm for inpatient RBC transfusions over a period of 8