Implementation of a Bleeding Risk Screening Tool and Hematology Referral Process Prior to Pediatric Endoscopy

OBJECTIVES

Gastrointestinal (GI) endoscopic procedures are considered low risk with an overall bleeding risk for upper and lower endoscopies of 0.11%. However, a certain population of patients may have a higher risk for bleeding, and there is not a standardized process for screening patients to determine who these patients are.

METHODS

At Children's Wisconsin, our gastroenterology and hematology divisions adapted an abbreviated version of a validated, history-based bleeding risk screening tool and implemented a hematology referral process to identify those at risk for bleeding prior to their first endoscopy. Provider compliance with the bleeding screen, referral to hematology, time to be seen in hematology clinic, new diagnoses of bleeding disorders, and bleeding complications were assessed from 2019 to 2021 across 3 phases.

RESULTS

Provider compliance with the bleeding screen improved throughout our study from 48% (120/251) to 75% (189/253). For those who screened positive, compliance with referral to hematology ranged from 38% to 74% across our phases. The overall time to be seen by hematology decreased from 30 days to 7.5 days. Eighteen patients ultimately screened positive and were seen in hematology clinic, of whom 22% (4/18) were diagnosed with a new bleeding disorder. No bleeding complications were seen in our study population.

CONCLUSIONS

Our quality improvement project provided a standardized screening tool to assess preoperative bleeding risk and reinforced the value of a history-based screening tool. This modified screening tool identified those with an undiagnosed bleeding disorder and preventative measures were undertaken to prevent procedural bleeding complications.

Endoscopic balloon dilation for management of stricturing Crohn’s disease in children

BACKGROUND

Crohn’s disease (CD) has a multitude of complications including intestinal strictures from fibrostenotic disease. Fibrostenotic disease has been reported in 10%-17% of children at presentation and leads to surgery in 20%-50% of cases within ten years of diagnosis. When symptoms develop from these strictures, the treatment in children has primarily been surgical resection. Endoscopic balloon dilation (EBD) has been shown to be a safe and efficacious alternative to surgery in adults, but evidence is poor in the literature regarding its safety and efficacy in children.

AIM

To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.

METHODS

In a single-center retrospective study, we looked at pediatric patients (ages 0-18) who carry the diagnosis of CD, who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1, 2012 through May 1, 2019. We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype. The type of intervention for patients’ strictures was then identified through procedural and surgical billing codes. We evaluated their demographics, clinical variables, whether they underwent EBD vs surgery or both, and their clinical outcomes.

RESULTS

Of the 139 patients with CD, 25 (18%) developed strictures. The initial intervention for a stricture was surgical resection in 12 patients (48%) and EBD in 13 patients (52%). However, 4 (33%) patients whom initially had surgical resection required follow up EBD, and thus 17 total patients (68%) underwent EBD at some point in their treatment process. For those 8 patients who underwent successful surgical resection alone, 4 of these patients (50%) had a fistula present near the stricture site and 4 (50%) had strictures greater than 5 cm in length. All patients who underwent EBD had no procedural complications, such as a perforation. Twenty-two (88%) of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.

CONCLUSION

EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.

Spiritual Distress Screening Using the Novel “Spirit 3” at Hospice Africa Uganda

Abstract 3

Background:

At Hospice Africa Uganda (HAU), patients' spiritual well-being is assessed in depth upon admission, but there are no rigorous assessment tools for regular spiritual distress screening in this setting. Our prior research demonstrated the “Spirit 8” assessment too cumbersome for routine use by HAU staff. The new “Spirit 3” includes three core questions thought to be most clinically relevant. The aims are to assess the feasibility of the Spirit 3 in routine screening for spiritual distress in hospice and to understand whether HAU staff value using the Spirit 3 in routine clinical practice.

Methods:

Between June 2014 and February 2015, the Spirit 3 was administered to consenting patients for four consecutive visits. The scale ranges from 3 to 15 with 15 representing an ideal state of spiritual well-being. For any patient unable to complete all assessments, a reason was recorded. Any staff intervention performed was recorded.

Results:

49 patients were enrolled in the study and completed the first assessment. 41 (84%) of those patients had untreatable, metastatic cancer and 8 (16%) had HIV/AIDS. Twenty patients (41%) completed the second assessment; 11 the third (23%); and 8 patients (16%) completed all 4 assessments. There were no partially completed assessments. Eight patients died prior to the second assessment; the remainder were missed by research staff during clinical care and thus lost to follow-up. At 86% of visits, a staff member performed an intervention to address the reported spiritual distress. Upon study completion, 75% of the HAU staff wished to use the Spirit 3 in routine clinical care.

Conclusion:

Almost half of living patients completed the second assessment (49%). Attrition was due to difficulty in flagging charts rather than any barriers in acceptance by patients or staff. The majority of HAU staff wished to continue using the Spirit 3 suggesting feasibility in clinical practice.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST:

No COIs from the authors.

Defining natural history: assessment of the ability of college students to aid in characterizing clinical progression of Niemann-Pick disease, type C

Niemann-Pick Disease, type C (NPC) is a fatal, neurodegenerative, lysosomal storage disorder. It is a rare disease with broad phenotypic spectrum and variable age of onset. These issues make it difficult to develop a universally accepted clinical outcome measure to assess urgently needed therapies. To this end, clinical investigators have defined emerging, disease severity scales. The average time from initial symptom to diagnosis is approximately 4 years. Further, some patients may not travel to specialized clinical centers even after diagnosis. We were therefore interested in investigating whether appropriately trained, community-based assessment of patient records could assist in defining disease progression using clinical severity scores. In this study we evolved a secure, step wise process to show that pre-existing medical records may be correctly assessed by non-clinical practitioners trained to quantify disease progression. Sixty-four undergraduate students at the University of Notre Dame were expertly trained in clinical disease assessment and recognition of major and minor symptoms of NPC. Seven clinical records, randomly selected from a total of thirty seven used to establish a leading clinical severity scale, were correctly assessed to show expected characteristics of linear disease progression. Student assessment of two new records donated by NPC families to our study also revealed linear progression of disease, but both showed accelerated disease progression, relative to the current severity scale, especially at the later stages. Together, these data suggest that college students may be trained in assessment of patient records, and thus provide insight into the natural history of a disease.