From the 2019 HVPAA National Conference
Dr. Michael Sydor (University of Texas Medical Branch), Dr. Bao Nguyen (University of Texas Medical Branch), Dr. Felippe Marcondes (University of Texas Medical Branch), Dr. Ahmed Chatila (University of Texas Medical Branch), Dr. Jordana Faruqi (University of Texas Medical Branch), Dr. Russell Roark (University of Texas Medical Branch), Dr. Rigoberto Garza (University of Texas Medical Branch), Dr. Rawan Dayah (University of Texas Medical Branch), Dr. Mayank Agarwal (University of Texas Medical Branch), Dr. Sarah Biggs (University of Texas Medical Branch), Dr. Sarah Tambra (University of Texas Medical Branch), Dr. Tehmina Khowaja (University of Texas Medical Branch), Dr. Chandi Kaushik (University of Texas Medical Branch), Dr. Ronald Samuel (University of Texas Medical Branch), Dr. Kevlin Kline (University of Texas Medical Branch), Dr. Lindsay Sonstein (University of Texas Medical Branch)
Background
Acute pancreatitis (AP) is the 3rd leading cause of gastroenterological disease related hospitalizations nationwide. AP is a diagnosis which benefits from multiple organizations, including the American College of Gastroenterology (ACG), publishing robust guidelines pertaining to the initial management and workup of these patients in the inpatient setting. In an effort to improve guideline-based care at our institution, we acquired retrospective data from 247 patients admitted to UTMB between April 1, 2015 to September 30, 2017 with acute pancreatitis. We identified multiple areas in which to improve care based on the ACG Guidelines: IVF resuscitation, right upper quadrant ultrasound (RUQ-US) use, and antibiotic stewardship in patients admitted with acute pancreatitis.
Objective
We aimed to increase the percentage of acute pancreatitis patients who receive adequate fluid resuscitation in the first 24 hours from 6.4% to 50%, increase the RUQ-US rate from 59.5% to 80%, and decrease the rate of inappropriate antibiotic use from 24% to 10%, by April 1, 2019.
Methods
Within the internal medicine department, a quality improvement group was assembled. Utilizing a fishbone diagram, barriers to implementing guideline-based care within our identified target areas were identified. We then implemented interventions, in a step wise manner, aimed at improving performance in our three focus areas. The interventions included: education to house staff in both internal and family medicine, development and implementation of an acute pancreatitis admission order set within the EPIC electronic medical record (EMR), meeting with the emergency medicine department to encourage early fluid resuscitation in AP patients, distribution of a management flowsheet to internal medicine house staff work rooms, and the antimicrobial stewardship program (ASP) including patients with AP who met criteria for inappropriate use (on antibiotics for >48 hours without evidence of intrapancreatic or extrapancreatic infection) for their EMR based communication. We tracked our progress in real time utilizing Sentri7 software, capturing patients using a cutoff of 3x the upper limit of normal of lipase and confirming the presence of AP in the EMR.
Results
On April 1st, a total of 43 patients were captured after the start of our interventions. Appropriate IVF resuscitation (defined as >250cc/hr of normal saline or lactated ringers (6L in the 1st 24 hours)) improved from 6.4% to 20.9%. RUQ-US obtained on admission improved from 59.5% to 67.4%. Inappropriate antibiotic use decreased from 24% to 14%.
Conclusions
While improvements in appropriate IVF resuscitation, RUQ-US rate, and antibiotic stewardship were noted, we have not yet met our goals. We intend to build on this progress through increased utilization of the AP order set, and the ASP will continue to monitor and intervene for inappropriate antibiotic use in AP patients. We intend to evaluate pre and post intervention 30 day readmission rates and length of stay.
Clinical Implications
Through this project we improved compliance with guideline-based care of patients with AP at our institution. Through these efforts we have developed durable mechanisms to continue to make further improvements. We anticipate that these changes will result in reduced length of day and 30 day readmission rates for our patients with AP.
