Children with heart disease have a greater risk of developing dangerous blood clots (thrombosis). The reasons are varied — heart defects that prevent normal pumping of blood, multiple surgeries, use of long-term IV lines — but the risks are very real and can be deadly.
To develop new strategies to reduce the incidence and complications of thrombosis in cardiac patients, clinicians at Children’s Hospital of Philadelphia (CHOP) began a two-year research project with funding from the Chair’s Initiatives.
More than a decade ago, CHOP’s Department of Pediatrics began the Chair’s Initiatives to establish new models of care in pediatrics and tackle some of the most daunting challenges in healthcare today. The program provides internal grants to support special projects throughout Children’s Hospital.
Thrombosis Prevention and Treatment in Cardiac Patients, led by Therese M. Giglia, MD, FACC, FAAP, SCCM, Attending Cardiologist and Medical Director of the Infant Single Ventricle Monitoring Program at the Cardiac Center, was one of five funded programs for 2013-2015.
Building on work from a previous Chair’s Initiative, the Thrombosis Prevention and Treatment team created guidelines and better care practices to prevent thrombosis and improve anticoagulant (blood-thinner) management for cardiac patients.
Over the course of two years, the team:
- Established practices and recommendations that reflected their project goal.
- Developed and implemented strategies to reduce incidence and complications of thrombosis in Cardiac Center inpatients.
- Improved outpatient anticoagulation monitoring and therapy.
Some of the specific strategies the clinical team at Children’s Hospital used to better identify and monitor at-risk patients included the following.
Weekly cardiac thrombosis rounds
By instituting weekly cardiac thrombosis rounds, the clinical team was able to discuss and define the management of cardiac inpatients and outpatients on thrombosis prevention and/or treatment. By the second year, the team was assessing two to five new patients a week, and monitoring another six to eight patients each week.
New clinical pathway
The clinical team developed a clinical pathway to better manage patients at increased risk of acute catheter-related venous thromboembolism. After one year, there was 80 percent complete clot resolution. Currently, development of a predictive model for venous thromboembolism in cardiac patients is underway.
Staffing and support
By adding a nurse practitioner with special training in thrombosis management, the team was able to see more patients and work with pharmacy staff to optimize anticoagulation and thrombotic therapy. In addition, the team implemented a consult service where doctors anywhere at Children’s Hospital could request help from a team of experts to better plan treatment for at-risk patients.
To better monitor patients, the team created a database to track cardiac patients under thrombosis or anticoagulant management, and established guidelines for bridging therapy in patients whose warfarin was interrupted.
With approval of Hospital leaders and national regulators, CHOP began a clinical trial using an anticoagulant called edoxaban in pediatric patients. The medication was approved by the U.S. Food and Drug Administration in 2015 to reduce the risk of stroke and blood clots in patients with atrial fibrillation.
The team also created discharge tools to better prepare families with children who have an increased risk of developing blood clots.
Moving forward, the team hopes to develop and validate a risk assessment model for venous thromboembolism in cardiac inpatients. Ultimately, they believe this model may help better identify patients most likely to benefit from thrombosis prophylaxis.
In addition, CHOP clinicians expect to increase services available for outpatients with the support of clinical pharmacists who have expertise in anticoagulation and thrombosis therapy.
Contributed by: Therese M. Giglia, MD, FACC, FAAP, SCCM