Design:  We met with the other fellows to discuss where potential delays and difficulties in the work-up and management of patients with low/absent TRECs were occurring within our system. We also completed a clinical process improvement leadership program course with this topic as our key project. We then reviewed the literature on low/absent TRECs and met with the primary immunodeficiency experts within our group as well as the pediatric allergy and immunology attendings to design a uniform approach to the work-up and management of these patients. We also created a smart phrase in our electronic medical record detailing how exactly to order and collect the labs required for this work-up as many are send outs and this often causes a delay. Lastly, we arranged a conference with the pediatric residents and attendings to discuss the clinical significance of this work-up their thoughts on ways to further improve the efficiency this process.

Main Findings:  There were differences within our group of which initial labs to send for these patients, and so work-up was delayed until formal staffing of the consult was done (often after hours due to clinic schedules.) There were significant delays in the ordered and collection of labs largely due to a knowledge gap of how to accomplish this, but also due to limited hours of the flow cytometry lab, and limited windows for send out labs, of which all all members of the teams were not aware given how infrequently these consults occurred. Overall, it was taking on average 36 hours from the time allergy was paged to the time the initial lab work-up was collected.

Impact on Practice:  This project has helped expedite the work-up and management of low/absent TRECs on the NBS within our practice. It has also decreased unnecessary and repetitive work for fellows and pediatric residents. Lastly, it afforded us an excellent teaching opportunity for our pediatric residents

Submitted by Elizabeth Yakaboski and Tina Motazedi, Massachusetts General Hospital