Improving Timely Treatment of Patients with Suspected TTP University of Alberta
Supervisor / Principle Investigator:
Dr. Linda Sun
Dr. Arabesque Parker
Dr. Daniel Sawler
MD Class of 2021
Introduction: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening condition that must be treated as a medical emergency to ensure that patients receive timely access to life saving plasma exchange. Plasma exchange, also referred to as plasmapheresis, has reduced mortality from as high as 90% to 10-20%. UK guidelines recommend initiating plasmapheresis in patients with suspected TTP within 4-8 hours of presentation. Timely definitive management of TTP is not being achieved in Northern Alberta. The current time from suspected diagnosis to plasmapheresis is 15.5 hours at the University of Alberta Hospital (UAH), the only centre with apheresis capacity in Northern Alberta. Delays in initiating plasmapheresis may directly impact patient outcome/mortality.
Our aim was to identify and implement salient interventions using cycle time analysis and the Shewhart Plan-Do-Study-Act iterative cycles to decrease the current cycle time within the TTP patient journey to achieve timely plasmapheresis treatment.
Methods: To define the problem and build understanding of the current process, a systematic quality improvement (QI) approach was used. The QI method included value stream mapping, cycle time and root cause (Ishikawa) analysis to identify areas of improvement opportunity. A chart audit of baseline data from patients presenting with suspected TTP from 2016-2017 showed that 9.3 hours was the median amount of time it took for a patient to receive plasmapheresis after arriving to the UAH emergency department. The greatest delay in patient care was in waiting for central line insertion by a trained physician, with a median wait time of 4.7 hrs. Among those with >8-hour delays from time of diagnosis and initiation of plasmapheresis, only 17% received plasma infusions as a temporizing measure. Plan-Do-Study Act cycles provided the framework to test the change interventions
Results: Based on baseline data, several interventions were identified. To address central line insertion as a source of delay, ICU and interventional radiology physicians were informed of urgent need to insert central lines on patients with suspected TTP. Selected dialysis nurses were cross-trained in plasmapheresis and may provide after-hours plasmapheresis coverage. , as PLEX is not available at UAH between 24:00 – 08:00. Hematology staff were informed to 1) order hemolysis workup as a STAT order to ensure lab work returns within 1 hour, 2) order plasma infusions for those with anticipated long delays to definitive treatment, as well as to 3) book transportation through RAAPID and to verbally request the patient to be transported as level red.
Conclusions: Through this project, we identified that communication gaps between medical services, transportation providers, and lab services are driving forces behind delays in treatment. Addressing these communication gaps will allow UAH to decrease cycle time, ultimately improving quality of patient care for those diagnosed with TTP.