(43) Enhancing Pediatric Bone Marrow Transplant Safety: Implementing Real-Time Alerts to Reduce Infection Risk

Title: Enhancing Pediatric Bone Marrow Transplant Safety: Implementing Real-Time Alerts to Reduce Infection Risk

Abstract : Basis of Inquiry
In March 2024, a safety concern was identified regarding the management of pediatric post-bone marrow transplantation (BMT) patients. Due to their immunocompromised status, these patients are at risk for severe infections. It was observed that patients were waiting in lobby areas rather than being immediately directed to private rooms, deviating from established protocols and unnecessarily increasing exposure risks.
Purpose
This initiative aimed to implement a real-time notification system to alert clinical staff upon patient check-in, facilitating immediate escort to a designated room. Additionally, concise guidelines were displayed in the alert for departments less familiar with the specific needs of this patient population. The objective of this initiative was to enhance the safety and quality of care for pediatric BMT patients. To achieve this, a tailored alert was developed to generate notifications for up to 100 days post-transplant, contingent upon a documented transplant status in the patient’s problem list.
Methods
A systematic, interdisciplinary approach was employed to modify existing clinical workflows and implement the alert system. Key factors considered in determining a reliable trigger for the alert included patient age, department, and oncology provider. Given that the pediatric oncology/BMT department treats patients over 17 years old, department-based triggers were deemed the most accurate. Close collaboration with relevant departments ensured accurate identification of our eligible patients. Given the differences between pediatric and adult protocols at our institution, the system was specifically designed for our pediatric care settings.
Outcomes
By August 2024, the project was complete with the successful deployment of a best practice advisory rule. This rule evaluates both the episode of care and the problem list to identify patients who have undergone BMT within the preceding 100 days. The implementation of this system ensures timely staff notifications, minimizes unnecessary exposure risks, and enhances patient safety outcomes.