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Scientific Abstracts North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Annual Meeting November 1 - 4, 2017 Las Vegas, NV Scientific Abstracts Vol. 65, Supplement 2, November 2017 S1 POSTER SESSION I Thursday, November 2 5:00pm – 7:00pm *Posters of Distinction ENDOSCOPY/QI/EDUCATION 3 IMPROVING QUALITY AND UTILIZATION OF ANTI-TNF POST-INDUCTION THERAPEUTIC DRUG MONITORING. Amy Peasley, Emily Homan, Amy Donegan, Ross Maltz, Jennifer Dotson, Wallace Crandall, Brendan Boyle. Gastroenterology, Nationwide Children’s Hospital, Columbus, OH Background: Anti-tumor necrosis factor (TNF) therapy has revolutionized the care of pediatric patients with moderate to severe Crohn’s disease and ulcerative colitis. However, an estimated 40% of patients who initially respond to an anti-TNF will lose response within the first 12 months of initiation. Loss of response can have significant clinical consequences as alternative medical therapies after failing an anti-TNF medication are limited. Because of the high rate of loss of response and the limited treatment options available to these patients, a focus upon individualized care and optimization of anti-TNF therapy through therapeutic drug monitoring (TDM) has continued to grow. TDM ensures adequate serum drug levels in order to minimize antibody formation and maintain disease control. Detectable serum drug levels have been associated with higher rates of clinical remission, lower C-reactive protein, and endoscopic healing. Proactive TDM has been associated with greater drug durability, reduced formation of antibodies, and reduced risk of IBD-related surgery and hospitalization. We aim to describe the quality improvement (QI) methods used at our institution to improve post-induction TDM in children initiating anti-TNF therapy, and to optimize our use of these medications through dose adjustments. Methods: This QI initiative was started in February 2016. All patients initiating anti-TNF therapy were identified and tracked. We defined the post-induction period for infliximab as any level obtained within 15 weeks of the first dose. We defined the post-induction period for adalimumab as any level drawn between 8-12 weeks of the first dose. PDSA cycles included the initiation of therapy plans for infliximab, modifications of electron medical record (EMR) strategies for consistent ordering of labs, real-time reminders for practitioners, and scheduling modifications within 6-8 weeks after anti-TNF therapy initiation. Baseline data from prior to 2016 was compared to data after initiation of the QI project. Results: In 2015, 85 patients began anti-TNF therapy (56 infliximab (66%) and 29 adalimumab (34%) within our IBD center. Among these patients, 35/85 (41%) had post-induction anti-TNF levels obtained. In 2015, 30/56 infliximab post-induction levels were obtained (54%) and 5/29 adalimumab post-induction levels were obtained (17%). In 2016, 89 patients began anti-TNF initiations (41 infliximab (46%) and 48 adalimumab (54%). Among those 89 new starts in 2016, 69 post- induction levels were obtained (78%). There were 30/41 post-induction infliximab levels obtained (73%) and 39/54 post-induction adalimumab levels obtained (81%). There were 20 missed opportunities due to process failures, patient no show, lab collection error, infusion reaction, and surgery. Vol. 65, Supplement 2, November 2017 S2 Conclusions: Through quality improvement methodology, we have improved our use of post-induction anti-TNF TDM from a baseline of about 41% to almost 80% within 1 year. Monthly data indicate 85-100% compliance with post-induction TDM since August 2016. Future studies will compare clinical outcomes after project initiation with a historical cohort. 4 MULTIDISCIPLINARY CLINIC APPROACH FOR THE CARE OF CHILDREN WITH INTESTINAL FAILURE- MAINTAINING EFFICIENCY IN A HIGH VOLUME CLINIC Andrea Martinez1,4, Matthew Nelson2, David During2, Debra Harrison4, Karen Steinberg4, Glenda Courtney-Martin4, Christina Kosar4, Paul W. Wales4,3, Yaron Avitzur1,4. 1Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, ON, Canada; 2Process Improvement and Innovation Team, Hospital for Sick Children, Toronto, ON, Canada; 3Division of General Surgery, Hospital for Sick Children, Toronto, ON, Canada; 4Group for the Improvement of Intestinal Failure and Treatment, Hospital for Sick Children, Toronto, ON, Canada Background: Children with intestinal failure benefit from multidisciplinary care. Since 2005, our intestinal rehabilitation (IR) clinic has fostered a multidisciplinary approach that includes a surgeon, gastroenterologist, nurse practitioners, dietitians, social worker, occupational therapist, physiotherapist and a speech pathologist. The team provides a simultaneous multidisciplinary assessment and care plan to the patient and family. This model is effective clinically, but time and resource consuming. With the growth in patient population, prolonged clinic wait times compromised the patient experience. We aimed to reorganize the IR clinic while maintaining the multidisciplinary model to improve clinic flow, efficiency and patient/family experience. Methods: We determined outcome, process and balance measures, administered questionnaire and performed value stream mapping to understand current clinic status and identify areas of opportunity. Real-time measurement of the clinic process was completed. Through LEAN methodology, 8 wastes were identified and PDSA cycle was created and implemented in the clinic. After 6 months real-time measurement was performed to assess the impact of these changes. Results: The patient survey demonstrated mean overall clinic satisfaction of 9.5/10; however, wait time score was 4.2. A new template for efficient multidisciplinary patient focused discussion and simultaneous follow up with re-organization of the clinic visit were created. Average appointment time before and after implementation were 114.28 min (SD 60.96 min) vs 65.10 min (SD 30.60 min) respectively. Before implementation, non-value added time (Amount of time that does not directly involve patient care), exceeded value added time (Amount of time involves patient interaction/care). After implementation value added time and team consult time increased from average 25.17 min to 27.44 min and 15.12 min to 18.05 min respectively. Measurement after implementing changes showed a reduction in clinic time by 44% and increased value added time by 9%. Conclusions: As the number of children with IF grows, efficient structure of the IR multidisciplinary clinic is essential for optimal patient care. Our project demonstrates the feasibility of stream-lined care delivery without compromising the benefit of a multi-member, simultaneous assessment clinic and providing better care and more valuable time for the patients. 5 ESOPHAGEAL CAPSULE ENDOSCOPY (ECE) IN CHILDREN AND YOUNG ADULTS. Anita Pai, Maureen Jonas, Victor Fox. Pediatric Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA Background: Variceal hemorrhage (VH) is a serious complication of portal hypertension (PH). Screening PH patients for varices and implementing prophylactic measures reduces VH risk. Data on ECE variceal detection in adults has been promising, but pediatric experience is limited. Methods: A cohort of children and young adults with suspected PH referred for variceal screening or surveillance at Boston Children’s Hospital (2005-2017) was offered ECE. A standard ingestion protocol was used. Clinical data, ECE performance, findings, and consequences of results were reviewed retrospectively. Results: 141 ECE studies (30 serial cases) were performed in 94 patients (53 males, 56.4%) using 3 ECE devices (PillCam™ ESO: 65, ESO2: 67, and UGI Capsule: 9). Videos were interpreted by 3 readers (#1: 122, 88.4%, #2: 14, 10.1%, #3: 2, 1.4%). Median age was 16y (IQR 4.8). Primary diagnosis: cholestatic (n=42, 29.8%), hepatocellular (n=9, 6.4%), metabolic (14, 9.9%), cystic fibrosis (n=39, 27.6%), pre-hepatic vascular (14, 9.9%), post-hepatic vascular (17, 12.1%), cryptogenic (6, 4.3%). There were 15 congenital heart cases (median 18.1y, IQR 4.7y; median Fontan pressure: 17, IQR 7.3 mmHg). 29 cases had a prior history of GI bleeding (GIB), 6 in the preceding 12 months. Median esophageal transit time (ETT) was 00m:20s (IQR 02m:20s) and study duration 31m:54s (IQR 11m:30s). 3 cases (ages 10.7, 11, 11.9y) were aborted due to difficulty swallowing capsules. Of the 138 ingested capsules, the final image was Vol. 65, Supplement 2, November 2017 S3 in the esophagus (2, 1.4 %), stomach (64, 46.4%), or post-pyloric (72, 52.2%). ECE detected varices in 62 cases (44.9%), including 57 esophageal, 17 gastric, and 6 duodenal. Small (49), medium (18), and large (5) varices were found in the distal (55), mid (4), and proximal (3) esophagus. Post-Fontan cases had median ETT of 05m:02s (IQR 09m:42s) and 3 “downhill”, 4 small distal, and 0 large varices. ECE also detected portal gastropathy (25, 18.1%), esophagitis (20, 14.5%), ulcers (5, 3.6%), erythema (26, 18.8%), erosions (31, 22.5%), heterotopic tissue (13, 9.4%), blood flecks (23, 16.7%), and mucosal scars from prior ligation (17, 12.3%). There were 2 transient capsule retentions and no major adverse events. ECE results led to follow-up EGD in 10 (6 variceal banding) and medication initiation in 11 (4 proton-pump inhibitor, 6 non-selective beta blocker, 2 other) cases. 4 patients had GIB within 12 months of ECE attempt (1 after aborted ECE). Conclusion: ECE is a feasible alternative
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