Making Every Drop Count for Pediatric Kidney Transplant Patients

Abstract

EIA is a recurring section of HospitalThere has to be a better way. This mantra reverberates in the minds of trainees throughout medical school, residency, and fellowship as they try to understand why certain decisions are made, how specifi c processes became standard work, and why these processes vary so greatly between institutions. When faced with ineffi cient, unsafe, or low-value care, we often fail to question or take action to fi nd and implement a better way. Trainees face an intimidating culture of hierarchy, which often hinders their drive to speak up about patient safety issues or raise questions about a process. 1 This environment can also limit their desire to challenge the system and make improvements. We are called to be good stewards of health care resources, and we simultaneously strive to improve the patient experience, improve the health of populations, and reduce costs.2,3 As I refl ected on the experience described here and considered my obligation to improve care, I reviewed the current process in place for monitoring tacrolimus levels for kidney transplant patients admitted to the nephrology fl oor in my institution.All pediatric solid organ transplant recipients take a regimen of immunosuppressive medications to prevent transplant rejection. Most of these regimens include a potent immunosuppressive medication with a narrow therapeutic window and concentration levels that are highly variable, both between patients and within individual patients. 4 The side effects of tacrolimus are concentration dependent and numerous; they include nephrotoxicity, neurotoxicity, hypertension, infection, glucose intolerance, liver dysfunction, and lymphoproliferative disease. 4,5

Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods

“…14 -16 Routine laboratory tests in the inpatient setting are frequently ordered but often not expected to return abnormal results. 17 -22 This excess testing may result in pain from phlebotomy, 23,24 anemia from excess blood loss, 25,26 and poor sleep for patients and caregivers from earlymorning laboratory draws. 27 -30 In some cases, excessive testing may also lead to a cascade of repeated testing after false-positive results, especially in tests organized as panels, for which the overall chance of a false-positive increases.…”