Faculty Bibliography

Background: The direct admissions process is an intricate patient care model that is affected by gaps in communication as well as unforeseen deviations that have the potential to negatively impact patient safety as well as decrease patient/family and provider satisfaction. This is especially true when dealing with a high-risk pediatric oncology population. In order to optimize this aspect of transition of care, we sought to establish and sustain a system to restructure our workflow for planned inpatient chemotherapy admissions.
Objective(s): Our smart aim was to streamline the admission process to decrease the rate of unplanned chemotherapy admissions from the pre-intervention baseline of 32.5% to 15% within 3 months. This was based on our global aim of improving logistics as well as stakeholder satisfaction with the planned admissions process for scheduled chemotherapy. Design/Method: Key stakeholders in the process were administered brief 5 question surveys to identify the key drivers in the current planned admissions process. Using Plan-Do-Study-Act (PDSA) quality improvement methodology, we identified areas of potential intervention. Our first PDSA cycle included education on the planned admission process, discussion of planned admissions at our weekly, multidisciplinary, divisional sign-out meeting and implementation of a calendar to document admissions in advance along with the chemotherapy to be administered. This new workflow replaced our previous emailbased admission notification system. A short survey was again administered at the end of the PDSA cycle to assess stakeholder satisfaction and identify other areas for improvement.
Result(s): Within the last 3 months, our rate of unplanned admissions has decreased below our anticipated goal to a level of 8%. Analyzing the post-intervention surveys, providers were satisfied with the new workflow, but still noted deficiencies in the multidisciplinary communication when pertaining to admitting patients. While this rate will likely never decline down to zero due to the constant presence of unforeseen clinical circumstances and changes in patients' status, we hypothesize that a lower rate of unexpected events will improve patient safety and satisfaction.
Conclusion(s): We hope to be able to continue this reduction of unplanned admissions through maintaining this standardized process. Future PDSA cycles will focus on improving communication about admissions and the establishment of a standardized admission checklist

Acute lymphoblastic leukemia (ALL) in infants below 1 year of age accounts for 2.5% to 5% of childhood ALL. Most children with ALL present with fever, bruising, mucosal bleeding, bone pain, pallor, hepatosplenomegaly, and lymphadenopathy. Common sites of extramedullary involvement at diagnosis include liver, spleen, lymph nodes, brain, and testes. Nephromegaly has also been reported. We present a novel case of bilateral parotid enlargement along with bilateral palpable nephromegaly in a patient with newly diagnosed infant ALL. This unique presentation highlights the importance of considering ALL in the differential diagnosis of parotid enlargement especially when associated with abnormal blood counts.

Miloh T, Arnon R, Roman E, Hurlet A, Kerkar N, Wistinghausen B. Autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura in pediatric solid organ transplant recipients, report of five cases and review of the literature. Pediatr Transplantation 2011: 15: 870-878. (c) 2011 John Wiley & Sons A/S. Abstract: Cytopenias are common among pediatric SOT; however, autoimmune cytopenias are infrequently reported. We report five cases of autoimmune cytopenias in pediatric LT patients: two with isolated IgG-mediated AIHA, two with ITP, and one with Evans syndrome (ITP and AIHA). All patients were maintained on tacrolimus as immunosuppression. Viral illness commonly preceded the autoimmune cytopenias. All patients responded well to medical therapy (steroids, intravenous immunoglobulin, and rituximab) and lowering tacrolimus serum level. Prognosis appears to be worse when more than one cell line (e.g., Evans syndrome) is affected, and/or there is no preceding viral illness. A critical literature review of autoimmune cytopenias in children following SOT is conducted. Autoimmune cytopenias are a rarely reported complication of pediatric SOT, but clinicians taking care of pediatric transplant recipients need to be aware of this complication