In-Service Education and Changes to the Electronic Health Record System Improve Intravenous Fluid Hydration in the Emergency Department in Patients With a Diagnosis of Acute Pancreatitis

Abstract

According to ACG guidelines, initial management of acute pancreatitis includes aggressive hydration defined as 250-500 mL/hr of isotonic crystalloid solution. Based on literature, morbidity and mortality can be further reduced with early resuscitation of a bolus of at least 1 L followed by a rate of infusion at 250 mL/hr. The purpose of our study is to evaluate if providing education and including an option for infusions in an existing order set available to Emergency Department (ED) providers improves the adequacy of early fluid hydration in patients diagnosed with acute pancreatitis. Initially, we generated a list of adult patients who presented to the ED with acute pancreatitis during a 12 month period. A chart review was performed to obtain the demographic data, cause of pancreatitis, type and amount of bolus infusate, type and rate of infusion received in the ED and if there was a reason provided in the ED provider’s note when patients received less than 1L bolus and 250 mL/hr infusion. The results were presented to the ED providers. Barriers to giving adequate IV fluid hydration in the ED were identified. Changes were made to the electronic health record (EHR) system in the quick order section to include fluid infusion and in-service education about adequate fluid resuscitation in acute pancreatitis was provided to the ED providers. The study was then repeated over 7 months to detect an improvement. A total of 100 patients were diagnosed with acute pancreatitis in the ED in 12 months. Twenty eight percent of patients did not receive adequate fluid resuscitation (without medical explanation). After the in-service education was provided and change was made in the EHR system, 52 patients were diagnosed with acute pancreatitis in the ED in 7 months. Twenty one percent of patients did not receive adequate fluid resuscitation but two patients had a medical explanation for it. The proportion of patients receiving an inadequate bolus and infusion declined from 28% to 21%. Statistically this difference is not significant (test statistic of 0.937 vs critical value of 1.645). The proportion of patients receiving an inadequate infusion showed a significant decline from 85% to 50% (test statistic of 4.613). The proportion of patients receiving inadequate bolus increased from 23% to 38.5% (test statistic of 2.013). Based on our analysis, an unacceptably high percentage of patients are receiving inadequate fluid hydration in our ED. After in-service education was provided and changes were implemented in the EHR system, there was statistically significant improvement in the number of patients receiving adequate infusions but a decline in boluses that were given. This may suggest increased efficiency in navigating the EHR potentially made a more significant impact on outcomes than in-service education.