478 - Multidisciplinary Development and Results of Implementation of Inpatient Treatment Pathway for Kawasaki Disease

Publication Number: 478.5887

Maria G. Biancarelli, Boston Children's Hospital, Brookline, MA, United States; Daniel Kelly, Boston Children's Hospital, Boston, MA, United States; Anthony Dekermanji, Boston Children's Hospital, Boston, MA, United States; Benjamin Ethier, Boston Children's Hospital, San Diego, CA, United States; Melissa Hazen, Boston Children's Hospital, Boston, MA, United States; Annette L. Baker, Boston Children's Hospital, Boston, MA, United States; Jane W.. Newburger, Harvard Medical School/Boston Children's Hospital, Boston, MA, United States; Mary Beth F.. Son, Boston Children's Hospital, Brookline, MA, United States; Olha Halyabar, Boston Children's Hospital, Boston, MA, United States

Background: Primary treatment intensification for patients with Kawasaki disease (KD) at high-risk of coronary artery aneurisms (CAA) decreases aneurism progression rate. Glucocorticoids are well established as primary adjunctive KD treatment and improve CA abnormalities in the acute phase. Given the multidisciplinary approach required to treat KD and lack of high evidence standard treatment for patients at high-risk for CAAs, we sought to improve identification and timely treatment with addition of steroids to Intravenous immunoglobulin (IVIG) in at-risk patients.

Objective: To standardize the interdisciplinary treatment in patients with KD; Improve time from admission to IVIG administration from 23.9 to 14 hours; And identify and treat high risk-patients as early as possible in the acute phase by decreasing time from IVIG to steroids order from 11.5 hours to 4 hours.

Design/Methods: After assessing the current state, the improvement team engaged a multifaceted intervention approach, including design and implementation of a clinical pathway based on best practice guidelines and expert opinion from key internal stakeholders. The pathway launched in June 2019 with multiple implementation strategies including education, socialization, order set development, and performance feedback. Outcome and process measures were evaluated using Statistical Process Control i-charts. Patients who were diagnosed and initially treated with KD in another institution, had atypical clinical presentation with plausible alternative initial diagnosis, or had limited initial echocardiogram were excluded.

Results: Post pathway implementation, time from admission to initial IVIG order demonstrated a mean shift from 23.9 hours to 13 hours, exceeding the 14-hour target (Fig 1). Decrease in time from IVIG order to steroid administration met special cause variation with a mean shift from 11.5 hours to 4.3 hours, and further decreased to 2.6 hours, exceeding the 4-hour target (Fig 2). IVIG order time to discharge shifted from a mean of 4.3 days to 2.3 days, exceeding the 3.5-day target.

Conclusion(s): Development and implementation of an inpatient KD treatment pathway effectively decreased the time between admission and primary treatment (IVIG) administration in all patients with KD and improved the timeliness of glucocorticoids administration as adjunctive therapy in the acute phase for patients at high-risk of CAAs. We identified no severe complications from corticosteroids. There were no major changes in clinical team structure or workflow to alternatively explain the improvements.

Figure 1- Time from Admission to Time of IVIG Order
Statistical Process Control i-chart showing that the baseline mean time from admission to time to IVIG order was 23.9 hours. There was special cause variation with a mean shift to 13 hours coinciding with KD pathway popularization, which has remained stable since 2018.

Figure 2- Time from IVIG Order to Steroid Administration
Statistical Process Control i-chart showing that the mean time from IVIG order to initiation of IV methylprednisolone as part of primary intensification treatment regimen for high-risk patients improved from a mean of 11.5 hours to 4.3 hours, coinciding with pathway awareness spread and posting on website, with most recent further improvement to a mean of 2.6 hours.