Improving care through standardization

Abstract

There is clear evidence that standardizing care in medicine improves outcomes. Despite this, care of many medical conditions in pediatrics is not standardized and varies considerably between providers. Management of children with acute pancreatitis (AP) is one example where there is a total lack of standardization of initial care. In adults with acute pancreatitis, initial aggressive intravenous (IV) fluid administration and early initiation of enteral nutrition are associated with better outcomes. Both are now recommended in guidelines for management of AP by the American College of Gastroenterology. Currently there are no such recommendations for the pediatric age group. The type and rate of IV fluid administration given to children is highly variable and onset of enteral nutrition often is delayed for prolonged periods. In this issue of The Journal, Szabo et al address the issue of initial management of children with mild AP. Based on a survey, they first documented that treatment of such children at their institution was highly variable. In order to have a more standardized approach to care they devised and implemented an admission order set in the electronic medical record (EMR) that provided recommendations for the type and rate of IV fluid administration and initiation of enteral nutrition upon admission for all children with mild AP. Outcomes for children treated prior to the EMR-based order set was compared with that of children treated using this standardized protocol. In essence, they demonstrated that early “aggressive” IV fluid administration and enteral nutrition are safe and associated with a decrease in length of hospital stay and rate of progression to severe pancreatitis. Although the design of this study does not allow us to assume that this should now be the standard of care for all children with mild AP, the apparent improvement in outcome is noteworthy and deserves further study. Perhaps more important is that this study once again demonstrates the potential value of standardizing care for children with medical conditions. Article page 397▶ Early Enteral Nutrition and Aggressive Fluid Resuscitation are Associated with Improved Clinical Outcomes in Acute PancreatitisThe Journal of PediatricsVol. 167Issue 2PreviewTo determine whether recommendations for treatment of acute pancreatitis (AP) in adults impact the outcomes of pediatric AP. Full-Text PDF