Implementation of a Process for Initial Transcranial Doppler Ultrasonography in Children With Sickle Cell Anemia

Abstract

Stroke, a devastating complication of sickle cell anemia (SCA), can cause irreversible brain injury with physical and cognitive deficits. Transcranial Doppler ultrasonography (TCD) is a non-invasive tool for identifying children with SCA at highest risk of stroke. National guidelines recommend that TCD screening begin at age 2 years, yet there is research to suggest less than half of young children undergo screening. The purpose of this project was to use quality improvement methods to improve the proportion of patients aged 24–27 months who successfully completed their initial TCD from 25% to 75% by December 31, 2013. Quality improvement methods (e.g., process mapping, simplified failure mode effect analysis, and plan–do–study–act cycles) were used to develop and test processes for identifying eligible patients, scheduling TCDs, preparing children and families for the first TCD, and monitoring outcomes (i.e., TCD protocol). Progress was tracked using a report of eligible patients and a chart showing the age in months for the first successful TCD (population metric). As of December 2013, 100% of eligible patients successfully completed their initial TCD screen; this improvement was maintained for the next 20 months. In November 2014, a Welch’s one-way ANOVA was conducted. Results showed a statistically significant difference between the average age of first TCD for eligible patients born in 2009 and eligible patients born during the intervention period (2010–2013; F[1,11.712]=16.03, p=0.002). Use of quality improvement methods to implement a TCD protocol was associated with improved TCD screening rates in young children with SCA.

Recommendation to reality: Closing the transcranial Doppler screening gap for children with sickle cell anemia

“…Our latest TCD screen rate estimates are as high as 80%, reflecting one of the highest sustained TCD screen rates reported in the literature. 5,6 Other prior studies that evaluated interventions to improve TCD screening rates were limited by short follow-up time period, 12 narrow age range of 24-27 months, 13 or involved personnel dedicated for TCD…”

Barriers to Pediatric Sickle Cell Disease Guideline Recommendations

“…Quality improvement methods to develop and implement a coordinated system for obtaining and improving the rates of initial TCD screenings for young children have been used and documented in a large health care system. 6 Incorporation of TCD screening within comprehensive SCD clinics during a comprehensive visit may be another strategy to improve patient adherence, outcomes, and satisfaction. 7 However, this approach may require a significant patient panel size to be cost-effective or practical.…”

Testing the Use of Data Drawn from the Electronic Health Record to Compare Quality

“…Using quality improvement methods for screening among 2 year olds, one sickle cell center increased the first-screening rates to 100% using quality improvement methods. 35 …”