Memorial Sloan Kettering Cancer Center

Improved Timely Diagnosis of Acute Limb Ischemia in a Cancer Center

Project Lead: Yolanda Bryce, MD

Project AIM(s):

Increase the percentage of patients with timely diagnosis of Acute Limb Ischemia (ALI) from 46% to 100% within 1 year utilizing the 3 proposed quality improvement initiatives:

  1. Development of an electronic alert mechanism for at-risk patients
  2. Development of a Rapid Response Team (RRT) activation model
  3. Implementation of regular pulse exams in patients at-risk for ALI

Narrative Description

We were not able to develop an electronic alert mechanism for at-risk patients. We attempted to approach this at many different angles and concepts. We had several meetings to engage the IT personnel in charge of our Computer Information System, Nursing Leadership, and members of clinical council. However, due to limitations of the electronic system (not a well-developed system for alerts), alert fatigue (many clinicians felt they already get too many alerts and did not want another one), and inconsistency of clinician documentation and use of variable patient surveys, questionnaires, and problem lists (clinicians sometimes free-text, use their own templates, and do not use the standardized problem lists), this was not established. Our hospital is switching to Epic in 2 years which appears to have more seamless use of patient questionnaires and problem lists. At that time, we will reattempt the creation and adoption of an alert system.

We were very successful in developing a rapid response team activation model. When there is suspicion of ALI, the Advanced Practitioner Personnel (APP)-mediated RRT responds and initiates the physical exam, correct imaging orders, and contacts Interventional Radiology, Vascular Surgery, and Hematology as needed. The RRT is concluded with a final disposition of the patient – either transfer to affiliate, treatment at MSKCC, or observation. We have had 9 patients go through this program successfully, with initiation of Heparin < 6 hours from presentation. The proposal passed through Clinical Council and the Hospital Medical Board and was implemented February 1, 2022.

We were unsuccessful in implementation of regular pulse exams in patients at-risk for ALI. We attempted to engage Nursing Leadership and Leadership in Quality Control however after many meetings and strategy discussions this was unsuccessful. However, we have provided many lectures to Nursing Staff, APP staff, Physician Trainees, and Physicians regarding ALI, peripheral arterial disease, and the need for regular pulse exams. The lectures have been well received and we hope it has raised awareness.

Tackling this problem of ALI at a cancer institute has been very rewarding. It has brought awareness to the problem and has improved care for our patients. Our goal and metric were to initiate heparin in < 6 hours from presentation as initiation of heparin > 6 hours from presentation was associated with the worse outcome (death, chronic limb threatening ischemia, life-style limiting claudication). We better understand the steps in implementing measures to improve diagnosis and timely treatment. Since the implementation of the ALI algorithm, we have also been involved with implementation of the Pulmonary Embolism Response Team. Having dealt with the ALI algorithm, this process was more intuitive and success was much easier to attain. Hopefully, we can continue to help many patients with vascular disease at our cancer institution where vascular disease is less understood.


Bryce Y, Emmanuel A Jr, Agrusa C, Ziv E, Harnain C, Huq S, Martin ES. Acute limb ischemia in a cancer patient has high morbidity, high mortality, and atypical presentation: a tertiary cancer center's retrospective study. BMC Cancer. 2021 Aug 13;21(1):916. doi: 10.1186/s12885-021-08659-x. PMID: 34388968; PMCID: PMC8361627.

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Patient delayed or unable to access to care
  • Information gathering
  • Information integration
  • Information interpretation
  • Establishing an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

  • Workflow (includes testing, follow-up, and referrals)
  • Health information sharing and accessibility via health IT
  • Knowledge gaps/inexperience

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)