Robinder Abrol, DO, Minh Tran, MD, Akhil Sood, MD, Brittany Duong, DO, Thomas Houghton, DO, Lauren Clark, MD, Lindsay Sonstein, MD, Ahmed Chatila, MD; University of Texas Medical Branch, Galveston, TX
Introduction: Cirrhosis is a leading cause of hospital admissions and significant healthcare resource utilization with patients commonly admitted for gastrointestinal bleeding (GIB), complications of ascites, or hepatic encephalopathy (HE). The American College of Gastroenterology and the American Association for The Study of Liver Diseases have published consensus guidelines outlining key diagnostic and management steps for the management of cirrhosis. We aim to evaluate our adherence to these guidelines and to implement institution-based practices to improve our guideline adherence in optimizing patient care and resource utilization. Methods: We designed a quality improvement project to better our adherence to guideline-based care in managing cirrhosis at our institution. All patients admitted with decompensated cirrhosis between June 2017 and March 2018 formed our baseline sample. Descriptive data and guideline benchmarks were collected. A Plan-Do-Study-Act (PDSA) model was used with the first cycle focused on electronic medical record (EMR)-based order-set changes and house staff education. The post-intervention group was comprised of all patients with decompensated cirrhosis admitted from February to August of 2019. Results: Of the 247 patients in our baseline and 53 patients in our post-intervention data were compared. At baseline, our pre-intervention sample had an average age of 60 and a mean Model for End Stage Liver Disease (MELD) score of 16.8, and our post-intervention data had a mean age of 54 and a mean MELD of 20. In patients admitted with ascites, time-to-paracentesis decreased from 17 to 14 hours, and patients receiving appropriate treatment for SBP increased from 39.1% to 75%. In patients with GIB, appropriate medical management with Proton Pump Inhibitors, Octreotide, and prophylactic antibiotics increased dramatically to 100% post-intervention. The average length of stay for patients after intervention was reduced from 6 days to 4.2 days. Discussion: Initial adherence to evidence-based guidelines in cirrhosis management was found to be suboptimal. Our project emphasized resident education, created concrete order sets, and provided ancillary staff training. Our quality improvement project demonstrates that EMR-based changes and improved house staff education improved adherence to guideline-based management of decompensated cirrhosis. Further iterations of our project will focus on continued resident education and reconstructing order sets based on growing/changing guidelines.
Cirrhosis Based Order Sets
Table 1. Characteristics of Patients with Cirrhosis
Table 2. Adherence to Guideline Based Care in Patients with Cirrhosis
Disclosures: Robinder Abrol indicated no relevant financial relationships. Minh Tran indicated no relevant financial relationships. Akhil Sood indicated no relevant financial relationships. Brittany Duong indicated no relevant financial relationships. Thomas Houghton indicated no relevant financial relationships. Lauren Clark indicated no relevant financial relationships. Lindsay Sonstein indicated no relevant financial relationships. Ahmed Chatila indicated no relevant financial relationships.