Patient Characteristics and Treatment Outcomes of Symptomatic Catheter-Related Arterial Thrombosis in Infants: A Retrospective Cohort Study.

OBJECTIVE: To describe the clinical characteristics, outcomes, and adverse events of treatment for symptomatic infant catheter-related arterial thrombosis. STUDY DESIGN: Single-center retrospective medical record review of 99 infants (age <365 days) with catheter-related arterial thrombosis, either following indwelling arterial catheter placement or cardiac catheterization, who were treated with anticoagulation over an 8-year span at a pediatric tertiary care center. Outcomes measured include thrombosis progression, bleeding events, and thrombus resolution following the treatment period. RESULTS: Thromboses were secondary to indwelling arterial catheter placement in 51 (51.5%) and cardiac catheterization in 48 (48.5%). The median age at diagnosis of catheter-related arterial thrombosis was 52 days. All patients received therapeutic anticoagulation with either unfractionated heparin or low molecular weight heparin for a maximum of 28 days. Progression of catheter-related arterial thrombosis occurred in 8 (8.1%) patients. One (1%) major and 3 (3%) minor bleeding events occurred within the cohort. Complete thrombus resolution was observed in 60 (60.6%), partial resolution in 33 (33.3%), and no resolution in 6 (6.1%) following the treatment period. Factors associated with complete thrombus resolution included time from intervention to catheter-related arterial thrombosis diagnosis (median of 1 day vs 5 days in those who experienced thrombus resolution vs those who did not, P = .035), and iliac and/or femoral artery involvement (P = .015). CONCLUSIONS: Our treatment approach to infant catheter-related arterial thrombosis is safe and effective. Limitations of the study are its retrospective nature with a limited number of patients from a single institution. Additional prospective studies are needed to determine the optimal treatment approach to catheter-related arterial thrombosis in infants.

Using Quality Improvement Methods to Implement an Electronic Medical Record (EMR) Supported Individualized Home Pain Management Plan for Children with Sickle Cell Disease.

OBJECTIVE: Using quality improvement methodology, our goal was to develop and implement individualized home pain management plans (HPMP) that included pharmacologic as well as non-pharmacologic strategies for children with sickle cell disease (SCD). We hypothesized that successfully implemented HPMPs would have an impact on Emergency Department (ED) use, decreasing ED visits for uncomplicated SCD pain episodes. METHODS: A multidisciplinary quality improvement team developed a questionnaire to assess the frequency, location and severity of a patient's pain during a routine, comprehensive visit in order to help the patient and family develop an effective pain management strategy using both pharmacologic and non-pharmacologic actions. Using plan do study act cycles (PDSAs), this team was able to build this process into the daily workflow for all SCD patients age 5 years to 21 years of age. Patients with comprehensive visits scheduled from January 2012 to May 2013 were included (N=188) in the intervention. RESULTS: By May of 2013, 88% of eligible patients had an individualized HPMP in place. There was a concomitant reduction in the percentage of SCD patients seen in the ED for uncomplicated SCD pain (6.9% vs. 1.1%). CONCLUSIONS: Using quality improvement methods, an individualized HPMP intervention was incorporated successfully into the daily workflow of a busy outpatient SCD clinic. This intervention has the potential to improve patient outcomes by decreasing avoidable ED visits as well as reducing overall healthcare costs.