WIP 10 - Quality Boost: Improving Post-Tonsillectomy Hemorrhage Care in the Pediatric ED with Nebulized TXA

Publication Number: WIP 10.7362

Kyna Donohue, Rady Children's Hospital San Diego, San Diego, CA, United States; Vijay Patel, Rady Children's Hospital / UCSD, San Diego, CA, United States; Daniel Roderick, Rady Children's Hospital San Diego, San Diego, CA, United States; Amy W. Bryl, Rady Children's Hospital/University of California San Diego, San Diego, CA, United States; Karen Yaphockun, Rady Children's Hospital San Diego, San Diego, CA, United States

Background: Tonsillectomy is one of the most performed pediatric surgeries in the US, and child post-tonsillectomy hemorrhage (PTH) rates are as high as 6.7%. Nebulized tranexamic acid (nTXA) is low in cost, safe, and effective in achieving hemostasis and decreasing the need for return to the OR (ROR) in PTH. Only 14% of patients who presented to the ED at a large pediatric emergency department during the baseline period received nTXA.

Objective: The global aim of the project is to improve management of PTH in the Pediatric ED. The smart aim is to increase the proportion of patients with PTH who receive nTXA from 14% to greater than 90%.

Design/Methods: This is an IRB-exempt Quality Improvement project conducted in the ED of a large academic children’s hospital. Baseline data was collected from June 2022 to May 2023. Inclusion criteria is age < 18, presentation ≤POD 14, and active bleeding or clot appreciated on examination. A failure mode and effects analysis was built to identify the systemic problems which preclude use of nTXA in eligible patients, and a key driver diagram was created which helped guide design of the project interventions. An ED clinical management guideline was developed with support from the ED and ENT divisions, and a corresponding ED EMR order set was implemented. The outcome measures will be the proportion of eligible patients who are treated with nTXA and the proportion with ROR. Process measures include time from both patient arrival and medication order to nTXA administration. Balancing measures include proportion admitted, proportion with return visits, length of stay, and appropriate nTXA dose.

The first PDSA cycle was aimed at education of PTA management for ED staff. The second PDSA cycle is ongoing and includes the implementation of a clinical management guideline and an ED EMR order set based on this.

Data is reviewed monthly. To date, the proportion of eligible patients who receive nTXA has increased from 14% to 70%. The time from patient arrival to receipt of nTXA has decreased from 111 minutes to a new baseline of 57 minutes.