Use of a Clinical Care Pathway for the Evaluation and

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Use of a Clinical Care Pathway for the Evaluation and Treatment of Children with Acute Chest Syndrome Tonya Ureda, MS, RN, FNP-BC Lauren Brown, MSN, CPNP-AC Shannon Davis, MSN, FNP-C, CPHON

Speaker Disclosure Statement

• Tonya Ureda has no industry relationships to disclose. • Lauren Brown has no industry relationships to disclose. • Shannon Davis has no industry relationships to disclose.

Objectives ➢Nurses will learn the definition of and pathophysiology of acute chest syndrome ➢Nurses will identify key components of a clinical care pathway for the evaluation and treatment of a child with acute chest syndrome ➢Nurses will learn how the implementation of a clinical care pathway can lead to decreased mortality and shortened length of stay ➢Nurses will be able to apply evidence-based recommendations for treatment of a child with acute chest syndrome into their daily practice

What is Acute Chest Syndrome? ➢Acute chest syndrome (ACS) is defined as development of a new pulmonary infiltrate with one or more of the following symptoms: • • • • •

Fever >38.5C Cough Chest pain Hypoxemia Tachypnea

➢Acute chest represents an acute lung injury caused by the adhesion of sickled RBCs to the pulmonary vasculature. This adhesion causes hypoxia, VQ mismatch, and inflammation

Risk Factors and Common Causes ➢Patients with increased risk for development of ACS: • • • • • •

Younger age More severe genotypes, ie. Hgb SS, Hbg S Beta 0 Thal Low fetal Hgb High Hgb S level at baseline Exposure to tobacco smoke in home environment History of asthma or reactive airway disease

➢Most common cause of ACS in the pediatric population is infection, however ACS can also occur in children with sickle cell admitted for vasocclusive crises or those that have received anesthesia

Mortality and Prolonged Hospitalization ➢ACS is the leading cause of death and hospitalization in children with sickle cell disease ➢Average hospitalization for these patients can be more than 10 days in duration ➢Prolonged hospitalization, secondary manifestations, and escalation of care compound for significant healthcare cost

Rationale for our Basis of Inquiry ➢Rapid identification and initiation of therapy for a patient with ACS can positively impact their overall outcome ➢Care of the patient with sickle cell disease is based on a multi disciplinary team approach ➢The implementation of standardized evidence based clinical care pathways are recommended to improve quality of care and to help reduce the length of hospitalization

Purpose ➢To develop a standardized clinical care pathway for the evaluation and treatment of children with acute chest syndrome ➢To minimize variations in practice amongst all health care team members ➢Develop a plan to monitor compliance with the clinical care pathway, length of hospitalization, and mortality rate

Methods ➢Guideline was developed through review and evaluation of published evidence ➢Consensus approval was obtained from all physicians, physician assistants, and nurse practitioners ➢Placed in institutional standardized format

➢Stored on common drive for access by all health care team members ➢Hard copy stored at nurses station on inpatient unit

Clinical Care Pathway

Clinical Care Pathway

Clinical Care Pathway

Clinical Care Pathway

Clinical Care Pathway

Clinical Care Pathway

Data Collection ➢Daily chart audits completed by sickle cell physician and inpatient nurse practitioners ➢Identify Sickle Cell patients with ACS • Compliance with clinical pathway • Transfusion Guidelines • Antibiotics – Inpatient and Outpatient • Oxygen therapy

• Length of Hospitalization • Mortality

Outcomes

➢89 episodes of acute chest syndrome • • • • •

January 1, 2016 to December 31, 2017 Ages 2-20 years of age 100% compliance - no deviations No mortalities Average hospital stay = 4.9 days

Conclusions

➢Evidence based guidelines • Ensures continuity of care among all providers • Decreased length of stay • Improved quality of care and patient outcomes

References • Bou-Maroun, LM., Meta, F., Hanba, CJ., Campbell, AD., Yanik, GA. (2018). An analysis of inpatient pediatric sickle cell disease: Incidence, costs, and outcomes. Pediatric Blood Cancer, 65(1). Doi:10.1002/pbc.26758 • Bundy, David G, MD, MPH., Richardson, Troy E, PhD., Hall, Matthew, PhD., et al.(2017) Association of Guideline-Adherent Antibiotic Treatment with Readmission of Children with Sickle Cell Disease Hospitalized with Acute Chest Syndrome. JAMA Pediatrics. 171(11). 1090-1099. doi:10.1001/jamapediatrics.2017.2526

• Jain, Shilpa, MD, MPH., Bakshi, Nitya, MDDB, MS., Krishnamurti, Lakshmanan, MD. (2017). Acute Chest Syndrome in Children with Sickle Cell Disease. Pediatric Allergy, Immunology, and Pulmonoogy, 30(4). doi: 10.1089/ped.2017.0814 • Khoury, RA., Musallam, KM., Mroueh, S., Abboud, MR. (2011) Pulmonary complications of sickle cell disease. Hemoglobin, 35(5-6)625-635. doi: 10.3109/03630269.2011.621149