Improving Safety of Botulinum Toxin Injections in a Pediatric Physical Medicine and Rehabilitation Clinic

Background and/or Objectives: Botulinum toxin injections (BTI) are commonly used to treat focal spasticity in children with disabilities. They are not without risks. Procedure checklists can reduce preventable harm, mortality, adverse events (AE), and near misses (NM) for patients in the surgical setting. Prompted by a preventable AE in a pediatric Physical Medicine & Rehabilitation clinic, the BTI procedure process was examined, and a checklist was developed. The primary aim was eliminating AE and NM with standardized BTI. Secondary aims included improving clinic workflow and reducing stress during BTI for patients, families, and staff.

Design: Quality improvement

Setting : Quality improvement

Participants : Caregivers of pediatric patients with developmental disabilities or cerebral palsy (n=20); clinic staff (n=3).

Interventions: A clinical procedure checklist was developed and implemented using a driver diagram and PDSA (Plan-Do-Study-Act) Model.

Main Outcome Measures: AE and NM were recorded in clinic. A phone survey was used to measure stress experienced by the caregiver and perceived stress experienced by the patient during BTI (n=20). A separate post-implementation survey was given to staff members (n=3) involved in rooming and positioning patients to measure stress and clinic workflow.

Results: Over 9 months of checklist implementation, 0 AE and NMs were recorded. All caregivers reported that their concerns were addressed, interactions with staff were calming or somewhat calming, and felt informed by discussion with staff. Regarding their child's perceived stress during BTI after checklist implementation, 80% of caregivers indicated no or minor stress, 15% felt no change, and 5% indicated high stress. After checklist implementation, 100% of staff reported that they felt the checklist had a positive impact on staff interactions and communication, improved workflow, and made BTI less stressful.

Conclusions: Implementation of a BTI checklist for pediatric patients with spasticity improved safety and workflow while reducing stress.