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BMJ Quality Improvement Report
Improving a process to obtain hepatitis B serology among patients treated with infliximab at a large urban children’s hospital
  1. M Raphaelle Jean1,
  2. Ann Weaver1,
  3. Teresa Mastin-Diebold1,
  4. Krista Kissinger1,
  5. Emily A Smitherman2,
  6. Leslie Favier2,
  7. Lara Danziger-Isakov3,
  8. Elizabeth Williams1,
  9. Rebecca C Brady3,
  10. Jennifer Huggins2,
  11. Lee A Denson1,
  12. Shehzad A Saeed1,
  13. Pamela Morgan1,
  14. Dana Michelle Hines Dykes1
  1. 1Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
  2. 2Division of Rheumatology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
  3. 3Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
  1. Correspondence to Dr Dana Michelle Hines Dykes; chellydykes{at}gmail.com

Abstract

Background Hepatitis B infection is a significant public health challenge despite improvements in vaccination efforts. Patients such as those on chronic immunosuppressive therapy for inflammatory bowel disease (IBD) or rheumatic disease may incur greater risk. The risk of reactivation of hepatitis B while on immunosuppressive therapy may have mortality rates up to 25%. These patients should be screened for acute or chronic infection and vaccinated if necessary. Our aim was to reliably complete hepatitis B screenings in patients receiving infliximab at Cincinnati Children’s Hospital Medical Center (CCHMC).

Methods Eligible patients included all patients with gastroenterology (GI) IBD and rheumatology receiving infliximab between October 2015 and March 2016. Using quality improvement methodology and the ‘plan–do–study–act’ (PDSA) approach, interventions centred around education of clinical providers, previsit planning and the development of ‘talking points’ for patients.

Results An initial screen of the IBD population revealed that 48% of the IBD patient population had been screened for anti-HBs alone, but no patients from GI or rheumatology divisions had a complete set of hepatitis B serology prior to the intervention including anti-Hep B Core and Hep B Surface Antigen. Seven PDSA cycles were performed during the 32-week intervention period, resulting in an increase in patients screened from 0% to ~85%. By March 2016, a total of 251 patients (201 GI, 50 rheumatology) had up-to-date hepatitis B serology screening. Automated ordering of the hepatitis B serology and ‘talking points’ for the provider had the greatest impact on successful screening.

Conclusions We developed a method to obtain hepatitis B serology on at-risk patients on infliximab within two subspecialty divisions within a large children’s hospital. Next steps will be to develop a process to reliably provide vaccines for patients who are seronegative, expand this process to all patients who are identified as immunocompromised within GI and rheumatology and then expand this process to other divisions at the CCHMC.

  • quality
  • immunosupression
  • hepatitis B
  • standardized care
  • infliximab

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjoq-2017-000092

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    Footnotes

    • Contributors Conception or design of the work: LAD, DMHD, MRJ, AW and TM-D. Data collection: MRJ, DMHD, AW, TM-D, KK, PM, JH, EAS, LF and EW. Data analysis and interpretation: MRJ, DMHD, LAD, PM, AW, TM-D, JH, EAS, LF and EW. Drafting the article: MRJ and DMHD. Critical revision of the article: DMHD, LAD, SAS, JH, EAS, LF, RCB and LDI. Final approval of the version to be published: DMHD, SS, LAD and MRJ.

    • Funding NIH T32 DK007727 PI Dr Lee A Denson; Pfizer 15448819 PI Dr Rebecca Brady.

    • Provenance and peer review Not commissioned; externally peer reviewed.