Indus Hospital & Health Network Reduces Oral Mucositis in Pediatric Oncology Through Structured Quality Improvement Initiative

Indus Hospital & Health Network manages a high/significant volume of childhood cancer patients in Pakistan. A substantial proportion of these children receive high-risk chemotherapy, placing them at risk of developing Oral Mucositis, a painful and often under-recognized treatment-related complication that adversely affects nutrition, increases infection risk, and can disrupt cancer therapy. In high-volume pediatric oncology settings, reducing the severity and frequency of such complications can significantly improve both patient outcomes and quality of life.

Against this backdrop, IHHN was selected as a participating site for a Quality Improvement (QI) Project under the St. Jude’s Global Alliance. Selection was driven not only by patient volume but also by IHHN’s capacity and excellence in embedding QI initiatives into routine clinical care. This initiative was implemented as a system-integrated quality improvement effort between December 2024 and 2025, aligned with everyday clinical workflows.

Central to the initiative was a multidisciplinary collaboration between Pediatric Oncology Nursing Consultants, Psychosocial Counsellors, and the Quality Improvement and Patient Safety (QIPS) team. Pediatric Oncology Nurses identified at-risk populations, provided education, and delivered supportive care. Consultants provided clinical expertise when needed, while psychosocial counsellors obtained patient satisfaction feedback about the initiative. QIPS provided the structured quality improvement framework, facilitating clinical audits, standardization of practices, and sustainable implementation. This collaboration ensured that interventions were practical, clinically relevant, and embedded within existing systems of care.

Baseline assessment revealed a 59% incidence of High-Grade Oral Mucositis among pediatric oncology patients receiving high-risk chemotherapy. Following implementation of targeted interventions, this rate declined to 47%, representing a meaningful reduction within a relatively short period and demonstrating the potential impact of structured, system-level improvements.

The initiative was operationalized through one-on-one coaching from St. Jude’s to introduce the MucoMAP Bundle at the grassroots level using education and communication across all components. A key insight was that caregivers often believed they were already familiar with oral hygiene practices; however, focused education revealed significant gaps in correct techniques and preventive care. As a result, Train-the-Trainer sessions were planned for healthcare staff, who in turn educated patients and caregivers, ensuring consistent understanding and application of oral care practices both in the hospital and at home.

Standardized oral assessment and documentation practices were introduced to address inconsistent recognition and recording of oral mucositis. WHO severity grading tools and documentation protocols enabled earlier identification, better monitoring, and more timely intervention. Basic oral care protocols, structured mouth-rinse guidance, and clear oral mucositis management recommendations were implemented across the department. In the absence of routine in-house dental services, innovative task shifting was employed, with dental specialists—primarily engaged in research roles within the team—receiving special departmental permissions to conduct bedside clinical dental assessments using standardized protocols. This approach provided critical oral health insights that had previously been unavailable within pediatric oncology care. Additionally, cryotherapy, which was not previously part of routine practice, was introduced as an adjunct intervention for selected chemotherapy regimens and showed encouraging early results in reducing oral mucositis severity.

To deepen impact and maximize the benefits of the pilot, a two-month focused implementation phase was conducted in December 2025 and January 2026. During this period, efforts across all key interventions were intentionally intensified through reinforced education, enhanced caregiver engagement, and increased dental support by collaborating with an esteemed team of periodontologists led by Dr. Ujala Faisal from Jinnah Medical & Dental College. They conducted targeted oral health awareness sessions focused on proper brushing techniques and caregiver-supported oral hygiene tailored for pediatric oncology patients. Their involvement enhanced both the credibility and effectiveness of the educational component. This concentrated phase emphasized translating knowledge into consistent bedside and home-based practice, helping to embed the interventions more firmly into routine care.

Overall, this initiative demonstrated the value of multidisciplinary collaboration supported by structured quality improvement in addressing treatment-related complications in pediatric oncology. By integrating education across interventions, standardizing assessment and documentation, introducing innovative dental assessments, and reinforcing practices through focused implementation, the project reduced the burden of oral mucositis and strengthened supportive care for children undergoing cancer treatment.