CHOA Heavy Menstrual Bleeding Guideline

By Amy Pattishall apattis@emory.edu

By Amy Pattishall
apattis@emory.edu

 

Heavy Menstrual Bleeding Guideline

Children’s Healthcare of Atlanta Emergency Department (ED) implemented one of its newest guidelines, for Heavy Menstrual Bleeding (HMB), in August 2016. This guideline represents a collaboration of several specialties, including Pediatric Emergency Medicine, Urgent Care, Hematology, Adolescent Medicine and Gynecology, with the goals of:

* Establishing a uniform process for evaluation and management of adolescents with HMB

* Reducing repeat visits to the ED for the same concern

* Expediting diagnosis of congenital bleeding disorders

* Improving the quality of life for adolescents experiencing HMB

* Providing improved opportunities for adolescent and gynecology follow up care

Why is such a guideline necessary?

Many adolescents with HMB present to the ED for evaluation, whether they are symptomatic or not. Evidence shows that patients presenting with HMB receive variable workups, potentially delaying diagnosis of bleeding disorders. This guideline helps to ensure that all adolescents at risk for a bleeding disorder receive appropriate laboratory evaluation and follow up with hematology or gynecology. HMB can also cause chronic iron deficiency anemia and affect adolescents’ quality of life. We hope the guideline will help improve patients’ quality of life by standardizing treatment for HMB.

Which patients are included in the guideline?

Any menstruating female with concern for HMB meets inclusion criteria. Patients with previously diagnosed bleeding disorders are excluded. The guideline incorporates an evidence-based screening tool to determine if laboratory workup for a congenital bleeding disorder is necessary, which is considered positive if the patient answers “yes” to any of the screening questions.

Screening Questions (Adapted from Claire Phillip Screening tool; AMJOG 2011):

1. On average does your period last 7 or more days?

2. Do you experience “flooding” or overflow bleeding through your tampon or pad?

3. Do you need to change your pad or tampon more than every 1-2 hours at times during your period?

4. Have you ever been treated (PO iron, IV iron, blood transfusions) for iron deficiency anemia in the past?

5. Do you have a family history of a bleeding disorder?

6. Have you had excessive bleeding with a dental extraction or dental surgery?

7. Have you had excessive bleeding with a miscarriage or following delivery of a child?

How do providers use the guideline?

The guideline stratifies patients based on severity of anemia and symptoms to help determine need for admission and IV versus oral medications. Recommendations on hormone and adjunct treatment (iron, anti-emetics, stool softeners) are included, as well as contact numbers for follow up at Emory Fellows’ Family Planning/Gynecology clinic, the Adolescent Medicine clinic at Hughes Spalding, and the CHOA Hematology clinic.

The HMB guideline, along with the full evidence summary, can be accessed on the CHOA Physician Portal: md.choa.org.

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Bronchiolitis Update 2015

By Maggie Kilgore and Javier Tejedor-Sojo

Margaret.Killgore@choa.org

javier.tejedor-sojo@choa.org

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As we move into bronchiolitis season, we wanted to remind you all of the new recommendations for inpatient and outpatient bronchiolitis treatment published by the AAP in 2014. These new recommendations were incorporated into Children’s Healthcare of Atlanta’s updated guidelines in the fall of 2014. Bronchiolitis is one of the top three admission diagnoses at Children’s. The 2014 Children’s guideline fosters patient-centered, value-based outcomes, more closely supports evidence-based therapies and interventions, and recommends that care providers deliver a consistent message to families.

Some of the key elements of the 2014 AAP guideline are that:

  • Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Chest X-Rays or laboratory studies should not be obtained routinely
  • Clinicians should not routinely administer albuterol or epinephrine to patients with a diagnosis of bronchiolitis
  • Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one
  • In infants with bronchiolitis, clinicians may choose not to administer supplemental oxygen if the O2 saturation exceeds 90%

It can be difficult to explain to families that the best treatment for their child is supportive care. The evidence and the new recommendations support that supportive care is what patients benefit from the most. In regards to albuterol, current recommendations discouraging its use in bronchiolitis are derived from the 2010 Cochrane review which included 10 inpatient and 10 outpatient trials. There was no statistical difference in the rate of hospitalization, length of hospitalization, oximetry nor time to resolution of illness at home between albuterol and placebo treated children. Some brief improvement in clinical respiratory scores was noted among outpatient and hospitalized patients but the standard mean difference was very small and no impact on clinical care would be expected.

There may be a sub-group of children with an underlying predisposition to asthma who may exhibit a response to albuterol. These children are generally older (>12 months) and have either a previous history of wheezing or atopy or a strong family history of asthma in first degree relatives. In the bronchiolitis guideline, these children may receive a single trial of albuterol without other concurrent interventions to determine whether they exhibit a positive clinical response to it. If they indeed have a positive documented response to albuterol these children would be managed under the ED/Inpatient asthma pathway.

Families should be educated that bronchiolitis is a disease that may last for two to three weeks. Many parents present for care because they are concerned their child is not feeding as usual. During the acute illness it is common and expected that children will feed less than their baseline. We need to help parents understand that if their child can sustain their basic fluid needs (even if they take sometimes half of what they typically drink), they are not likely to get dehydrated. Patients who maintain saturations >90% on room air, are able to handle secretions, and can maintain acceptable hydration and activity can generally be treated at home with supportive therapy.

On October 1, 2014 Children’s implemented the guidelines in the ED, Urgent Care, and Inpatient Settings. During the Sept 2014—April 2015 season, we decreased albuterol usage in 1-12 month olds with bronchiolitis from 45% to 25% in the ED and from 40% to 11% for patients who were admitted. We were able to achieve these results without negatively impacting our length of stay or 7 day readmission rate. Reducing the use of therapies that have not demonstrated benefit to our patients and helping them return home sooner if medically stable, is an example of delivering value to them and their families.

If there are any questions about the guideline, feel free to contact :

Dr Shabnam Jain sjain@emory.edu

Dr Tejedor-Sojo  javier.tejedor-sojo@choa.org

Please see the link below to the clinical guideline page on the physician portal for access to our guidelines, link to the AAP 2014 recommendations, and see Children’s full evidence summary that is posted on the physician portal:

https://md.choa.org/clinical-excellence/clinical-practice-guidelines/bronchiolitis