HPB P38 A Novel Ambulatory Pathway in the Management of Acute Pancreatitis

Abstract

Abstract Background The incidence of acute pancreatitis has doubled over the last two decades, accounting for approximately 20,000 UK inpatient admissions yearly1. The Atlanta Classification defines three severity grades, with over 90% of patients “mild” or “moderate” severity2,3. Validated risk-stratification tools including the Harmless Acute Pancreatitis Score(HAPS), supported by NEWS score, and biomarkers including CRP, predicts up to 97% of patients who will run a “mild” disease course; and are therefore suitable for ambulatory care4. Currently, however, these ambulatory pathways don’t exist. The main aim of the study was to develop a safe ambulatory pancreatitis pathway to reduce hospital admissions. Methods The study consists of four phases. Phase 1 involved development of an evidence-based, safe ambulatory pathway, based on HAPS and augmented with clinical/biochemical predictors of severe disease, complications, or mortality (See Figure 1). Phase 2 involved a 4-week retrospective analysis of all patients presenting with acute pancreatitis using the evidence-based pathway described above. Subsequent Atlanta classification, as well as documentation of complications/requirement for escalated care confirmed suitability for ambulatory care. Phase 3 is currently underway and involves piloting the pathway, and Phase 4 will consist of refining the pathway based on clinical, economic outcome measures and stakeholder views. Results Phase 1: Following literature review, use of HAPS, a CRP>100, neutrophils>15x109/l and NEWS of 2 or more, were identified as the most reliable severity scoring tools in acute pancreatitis. NEWS of 2 or more is an independent predictor of increased complications and resultant mortality. CRP and neutrophilia both have 90% sensitivity in predicting a severe disease course. Phase 2: 27 confirmed cases of acute pancreatitis were identified. Of these, five (alcohol-related in 3 and gallstone-related in 2) met the criteria for ambulatory care. Mean hospital stay was 6 days: no patients died, and none required escalation from ward-based care. Conclusions This retrospective analysis has shown that almost a fifth of patients with acute pancreatitis, admitted on the acute on-call take, could be managed in an ambulatory fashion as per currently established severity scoring criteria. Development of the ambulatory acute pancreatitis protocol required an integrated approach from key stakeholders including the emergency general and pancreatic surgical teams and ambulatory care staff. Further prospective analyses of the pathway will be required to identify its patient-reported satisfaction and economic benefits.