Introduction

Welcome to the APSA Quality and Safety Committee Thyroid Disease Toolkit. This topic is intended to help anyone who is interested in Quality Improvement (QI) pertaining to thyroid disease

and malignant thyroid tumors.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Thyroidectomy Protocols

In order to standardize the care provided by physicians, housestaff, and nurses pertaining to patients undergoing endocrine surgery, Mott Children’s Hospital developed the Multispecialty Pediatric Endocrine Surgery (MPES) protocols. This was a joint effort between pediatric surgeons, pediatric endocrinologists, and pediatric anesthesiologists.

Protocols:

• Mott MPES Thyroid Nodule Work-up
• Mott MPES Thyroid Cancer Protocol
• Mott Post-Thyroidectomy and Parathyroidectomy Protocol

Resources:

• Mott Medullary Thyroid Cancer Flow Chart
• Mott RET Mutations Table (MTC Risk, Pheo Risk, Hypothyroidism Risk)

Stakeholders: Pediatric Endocrinology, Pediatric Anesthesiology, Pediatric Surgery, MPES nurses

Challenges and solutions:

• Challenge:
  • The MPES clinic was developed and run by one pediatric surgeon and two endocrinologists. The MPES surgeon performs all of the operations. However, all pediatric surgeons and pediatric endocrinologists care for these patients post-operatively which leads to a variance in practice when dealing with postoperative issues.
• Solution: The MPES protocols allowed for standardization and publicity of the care of the MPES patients.

Links to published data (used to develop the protocol):

Submitted by: Steven Bruch, MD

At Nemours/Alfred I. Dupont Hospital for Children (AIDHC), a clinical practice guideline (CPG) was created for the preoperative work up and postoperative management of patients undergoing thyroidectomy. This includes Epic orders with labs and medications embedded. A thyroid surgery preoperative checklist for patients with thyroid neoplasms was also created to confirm the performance of the correct surgery and clarify areas of lymph node involvement.

Protocols:

• Nemours/AIDHC CPG for Total Throidectomy

Resources:

• Nemours/AIDHC EPIC Thyroid Surgery Preop Checklist
• Nemours/AIDHC Epic Thyroid Surgery Postop Admission Order Set

Stakeholders:

Challenges and solutions:

Links to published data (used to develop the protocol):

Submitted by: Loren Berman, MD

Children’s Healthcare of Atlanta (CHOA) created an Epic order set for patients undergoing total thyroidectomy to assist with the postoperative management of hypocalcemia. The Epic order set includes labs and medications with the goal of standardizing the care provided. The pediatric endocrinology team manages the medications.

Protocols:

• CHOA Key Driver Analysis Pediatric Total Thyroidectomy

Resources:

• CHOA Epic Postop Total Thyroidectomy Order Set
• CHOA Perioperative Hypocalcemia Management

Stakeholders: Pediatric Endocrinology, Pediatric Surgery

Challenges and solutions:

• Increase use of order set:
  • Through education and monitoring with direct feedback we were able to have sustained levels of order set use.
  • We also decreased the number of different surgeons performing thyroid surgery which allowed for higher volumes per surgeon and better compliance to the guidelines.
• Standardizing post-op management and management of calcium levels
  • We implemented that only one service, endocrinology, would manage post-op calcium levels. This decreased the confusion of who is responsible for the orders and eliminated incorrect or redundant orders.

Links to published data (used to develop the protocol): [1][2]

Submitted by: Matthew Santore, MD

Toolkit Curators

Monica Lopez, MD Benjamin Padilla, MD, Matthew Santore MD

Migration Editors

Raquel Gonzalez, MD, Kristen Kaiser, MD

References