What used to take physicians at Children’s Hospital Colorado 48 hours now takes only 15 hours, thanks to a multidisciplinary effort aimed at reducing the time to histological diagnosis of anterior mediastinal masses. This allows appropriate therapy to start sooner.
The project team included representatives from oncology, interventional radiology, anesthesia, surgery, pediatric intensive care, emergency department and radiology. They worked together to create an algorithm outlining each department’s role when treating this rare, potentially life threatening condition.
“An anterior mediastinal mass is often a rapidly-growing tumor that is compressing the child’s airway,” explained project sponsor Joanne M. Hilden, MD, (pictured on left), medical director of the Center for Cancer and Blood Disorders. “It’s an urgent medical emergency that requires biopsy to begin targeted treatment.”
Typically a patient presents to the emergency department, and an anterior mediastinal mass is diagnosed. A biopsy is needed to understand the nature of the mass. To accomplish the biopsy, the child needs to be assessed by anesthesiology in regards to the safest approach—local anesthesia, sedation or general anesthesia. But communication to anesthesia that the patient had an anterior mediastinal mass was inconsistent.
“Prior to the algorithm, team members might have assumed anesthesia was immediately notified of the mediastinal mass. But it wasn’t always the case. The procedure order might have said ‘lymph node biopsy’ or ‘mass biopsy,’” explained Gee Mei Tan, MD, (pictured on right), chair of Blood Utilization Review Team in anesthesiology. “These cases were usually an ‘add on’ to the schedule on the day of the procedure, and anesthesia might not have been aware of the mediastinal mass until we looked up the patient in the medical charts. This could cause a delay because we have to rethink our approach to anesthesia. We’d get the procedure done, but it may not have happened in a time that’s efficient.”
The immediate availability of specialty teams was also a barrier to diagnosis, particularly on weekends.
“We have a saying in our department that patients with an anterior mediastinal mass seem to present after hours on Friday nights or on the weekends when some of the specialty teams are not in the hospital,” said Dr. Tan. Without quick access to the specialists, diagnosis may be delayed.
Meanwhile, says Dr. Hilden, the tumor may be growing and further compressing the airway.
Lindsey Hoffman, DO, (pictured on left) began her career at Children’s Colorado as an oncology fellow. For her quality improvement project, she aimed to reduce the time to biopsy for these high risk patients. Dr. Hoffman – now a faculty member – helped the multidisciplinary team discover barriers to timely diagnosis and therapy. One barrier was inefficient communication.
Dr. Hilden recalls the disjointed process. “Diagnosing a mediastinal mass requires an entire team. Prior to the introduction of the algorithm, everyone on the team would be consulted independently,” she said. “You read consults, make your calls one at a time, and make a plan. Time would pass, and the next day a new on-call team would be making a new plan. It wasn’t the best system for our patients.”
Now, a face-to-face meeting or conference call that includes the entire team can occur if required as soon as a patient with an anterior mediastinal mass with airway compromise is admitted, which allows everyone involved to agree on the best approach. The conference call can be scheduled immediately, 24 hours a day, 365 days a year.
Anesthesia, surgery and interventional radiology have worked together to ensure these cases are safely biopsied in a timely fashion.
“Now that we’re working together as a multidisciplinary team, we’re able to make sure our high risk patients with high risk procedures are scheduled during the day,” said Dr. Tan.
The algorithm has already reduced the need for unnecessary radiation to reduce the mass prior to biopsy.
“Now no one gets radiation that their diagnosis of cancer would not have required,” said Dr. Hilden.
Above all, the team is encouraged by the progress they have already made, and they credit the willingness of all team members to work together.
“The project underscores the value of a team coming together on a patient’s behalf,” said Dr. Hilden.
Project contributors include: Joanne Hilden, MD, Kelly Maloney, MD, Lindsey Hoffman, DO, Tim Garrington, MD (oncology); Roger Harned, MD (interventional radiology); Gee Mei Tan, MD, Megan Brockel, MD (anesthesiology); Tim Crombleholme, MD, Jen Bruny, MD, Dave Partrick, MD (surgery), Todd Carpenter, MD (PICU), Savannah Ross, MD (pediatric resident) and Becky Coughlin (process improvement).
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