Use of American Society of Hematology ITP Guidelines to Decrease Hospitalizations and IVIG Use Among Children Presenting with Acute ITP to a Tertiary Care Pediatric Hospital - a Quality Improvement Project
Authors: Shah Sanjay J. , Nourani Mona , Knoll Christine M. 
Published: December 2024

Background
Immune thrombocytopenia (ITP) is a disorder characterized by thrombocytopenia caused by antibodies against platelet antigens. In 2019, the American Society of Hematology (ASH) published guidelines for treatment of ITP. The management of ITP at Phoenix Children's Hospital based on previous institutional guidelines suggested admission of any patient with platelet count of &lt; 10x109/L, and administration of intravenous immunoglobulin (IVIG) with any degree of epistaxis or mucosal bleeding. This led to significant admissions and IVIG use. Although effective, IVIG is known to cause hypersensitivity reaction and aseptic meningitis and is expensive. Outpatient treatment rather than hospitalization was recommended, per current ASH ITP guidelines, for children with newly diagnosed ITP with platelet count of &lt;20x109/L who have no or mild bleeding (skin manifestation). Also, in patients with non-life-threatening mucosal bleeding, the ASH guidelines panel suggests corticosteroids rather than IVIG. Therefore, an updated institutional algorithm was needed to align with new ASH guidelines.

Aim and Methods
The aim of this quality improvement (QI) project was to establish a new algorithm based on the 2019 ASH ITP guidelines and a new standard operating procedure to decrease the number of yearly admissions and IVIG use among pediatric patients with newly diagnosed ITP. The data on admissions and IVIG use were collected from three consecutive periods: 3/1/2021 to 3/31/2022 (pre-intervention), 4/1/2022 to 3/31/2023 (year 1) and 4/1/2023 to 3/31/2024 (year 2).
INTERVENTIONS
In March 2022, a new institutional guideline and an algorithm were developed based on the ASH ITP guidelines. Accordingly, if a patient presented to the emergency department (ED) with newly diagnosed ITP, the hematology service was consulted. If the patient fit predetermined criteria for discharge, the hematology provider provided detailed education to the family, either by phone or in person, and arranged a follow up within 2 days. Education material about ITP was included in the discharge report. If according to the algorithm (based on modified Buchanan bleeding score), the patient required treatment, a choice between steroids or IVIG treatment was made. IVIG was only to be used if a rapid increase in platelet count was needed or in life threatening situations. The new workflow was presented to hematology/oncology and ED providers and emailed to both departments. It was made easily available to all providers. Every ITP admission was reviewed and the reason for admission was discussed. If IVIG was used, the case was reviewed with the hematologist on service. The education was reinforced in 6 months to review the updated guidelines.

RESULTS
During the pre-intervention, post intervention year 1 and year 2; there were 30, 33 and 26 newly diagnosed ITP cases, respectively. Of these 26 (87%), 14 (42%) and 3 (12%) were admitted during the respective periods and 21 (70%), 8 (24%) and 3 (12%) patients received IVIG during the respective periods. All the differences were statistically significant. This resulted in cost savings for IVIG use of $88,000 in year 1 and $97,000 in year 2. This was in addition to healthcare dollars saved from avoiding admission and supportive care costs.

CONCLUSION
Implementation of standardized algorithm and guidelines for management of acute pediatric ITP based on current evidence resulted in significant reduction of hospitalizations, IVIG administration and healthcare related costs at a tertiary care center. Successful strategies included a thorough review and discussion of literature, securing provider buy-in, provider education, ready availability of guidelines at point-of-care, periodic reinforcement of education and cohesive teamwork.