01 Impact of the implementation of a revised practice guideline on hospitalization and treatment for the management of acute immune thrombocytopenia in children

Abstract Background Acute immune thrombocytopenia (aITP) is a common hematologic disorder in children. ITP is often transient, and severe bleeding rare despite low platelet counts. Observation without treatment is therefore deemed safe in the absence of significant bleeding. Current guidelines prioritize clinical bleeding scores over platelet counts for treatment decisions. Objectives This study assesses whether a bleeding score-based approach reduces treatment rates without increasing severe bleeding risk in paediatric acute ITP. Design/Methods Clinical practice guidelines for managing aITP in the emergency department (ED) were revised at CHU Sainte-Justine in September 2021. The new algorithm recommended treatment for patients with Buchanan bleeding score ≥3 without considering platelet count, while the previous one suggesting treatment with platelet count < 10x109/L. We compared patient management before (PRE group: Jan 2019–Dec 2020) and after (POST group: Jan 2022–Dec 2023) implementation. We included patients <18 years diagnosed with acute ITP in the ED. We used non-parametric Wilcoxon–Mann-Whitney and Fisher's exact tests for continuous and discrete variable, respectively. Results In the study period, 84 patients were included for analysis: 34 patients PRE and 50 POST. Mean age was 5 years and baseline characteristics did not differ between the two groups. The mean platelet count at diagnosis was <10 x109/L. In the POST period, the guideline was followed in 88% of cases. More patients were observed without treatment at diagnostic in the ED with the new guideline (PRE 24% [8/34], POST 58% [29/50] p=0.002). The effect was mainly due to a higher observation rate in patients with low bleeding score (PRE 32% [7/22], POST 84% [26/31] resulting in 52% increase of observation rate (RR 2.6, [95%CI 1.38-5.06]). Treatment initiation within 3 months also decreased (PRE 85% [29/34], POST 62% [31/50] p=0.027). Fewer patients were admitted to the hospital from the ED (PRE 62% [21/34], POST 22% [11/50] p=0,0005). No complications such as intracranial bleeding or death were observed. There was only 1 severe bleeding in PRE but none in POST. Conclusion Transitioning from platelet-based to bleeding-score based guideline reduced treatment use in the ED, and decreased hospitalizations. Importantly, no increase in severe bleeding or chronic ITP were identified. Collaboration between ED physicians, paediatricians, and hematologists ensured the guideline's feasibility, compliance and safety.

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