Q&A with PCH – Audrea Chen

Q&A with PCH features conversations with journal editors, authors, and more. In this Q&A session, we chatted with Dr. Audrea Chen, the first author of Streamlining Kawasaki disease care: a quality improvement initiative to safely reduce length of stay published in Paediatrics & Child Health. Watch the full video on our CPS YouTube page.

What is the core focus of the study and how is it relevant to paediatricians and health professionals across Canada?

The core focus of our study was finding a way to streamline care for children with Kawasaki disease (KD) so that they can safely spend less time in hospital. KD is an acute condition with sudden onset, causing fevers and inflammation of blood vessels. It is the leading cause of acquired pediatric heart disease worldwide. We aimed to do this by creating a standardized clinical pathway for patients with KD that encompassed admission to discharge. This project addresses a major priority because at the center where the project was conducted, there were approximately 100 admissions per year for this condition. Additionally, our pediatric inpatient units were operating consistently over 100% capacity. Furthermore, KD admissions are incredibly resource intensive on our healthcare professionals and our healthcare system. KD costs over six times more to treat compared to other causes of acute pediatric admissions. The driver of this increased cost is prolonged hospitalization, awaiting tests, and subspecialty consultation.

For families, a diagnosis of KD is often a sudden and distressing experience. This is often the patient's first encounter with the healthcare system where they must stay in an unfamiliar environment while being subjected to frequent tests and treatments. Families affected by KD report experiencing significantly more anxiety and lower quality of life within the first year after diagnosis compared to other pediatric admissions such as bronchiolitis or pneumonia. Much of this anxiety and worry has been attributed to a lack of clear disease-specific information.

In this project our goal was to not only make the system more efficient, but to also improve the experience for families by giving them better resources and a clearer path to going home. We hope that by publishing our clinical pathway and the rationale behind the development, other centers will be able to adapt the pathway to optimize their workflow, and it will help local context to improve patient experience and reduce the burden of inpatient admissions.

What were the key findings of the study?

The project was successful in that we achieved a 17% reduction in the average length of stay, bringing it down from ~ 55 to 46 hours over the course of one year of intervention. Although our team originally aimed for a bigger drop, the 17% reduction was sustained, and it saved about an estimated $25,000 over 49 admissions. These savings come from both a shorter length of stay and from eliminating unnecessary blood tests. Other interventions included streamlining the echocardiography booking process, developing a discharge checklist, requiring patients to be fever free for only about 24 hours prior to discharge, standardizing discharge instructions, and improving patient educational resources.

Our interventions were developed in collaboration with volunteers from Kawasaki Disease Canada, a national registered charity that advocates for families affected by KD and provides support for those who are newly diagnosed. They helped us develop this guidance with regards to expected symptoms following discharge, when to return to care, and when their child can return to activity. These are all common questions that can cause confusion and anxiety if not clarified ahead of time. The other major finding in our study was that there were no safety concerns: none of the patients with normal initial heart scans developed new aneurysms after discharge, and there weren't any cases of missed fevers between discharge and their first clinic follow-up. Furthermore, the earlier discharge did not result in increased access to emergency department care post-discharge. And lastly, caregiver satisfaction remained high and comparable to caregiver satisfaction across the hospital.

Families felt like they were getting comprehensive medical information and they felt more prepared for the follow-up process. It really showed that we can make these bold practice changes like shortening the admission and reducing blood work without putting children's safety at risk.

About Dr. Audrea Chen

Dr. Audrea Chen is a Pediatric Rheumatologist working at the Stollery Children's hospital. She did additional training in childhood vasculitis at the Hospital for Sick Children in Toronto as well as a Master of Science in Quality Improvement & Patient Safety. Dr. Chen’s research and QI work focuses on KD, systemic vasculitis, improving patient/family understanding of their disease and transition to adult care for patients with rheumatic disease.

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