Quality Gaps in the Management of Patients With Acute Pancreatitis

Abstract

Acute pancreatitis is the most common gastrointestinal cause for hospitalization and is associated with high morbidity and mortality. Multiple clinical guidelines outline best practices for the management of these patients. However, recent studies suggest that adherence to such guidelines is poor. In this study, we aim to audit current practice to identify potential targets for quality improvement initiatives. A retrospective chart review of all patients admitted directly to St Michael’s Hospital (a tertiary-care hospital) from the emergency department with a diagnosis of acute pancreatitis between January 1, 2016 and December 31, 2016 was performed. Complex patients transferred from another hospital to the intensive care unit or gastrointestinal ward were excluded. Potential quality indicators were extracted from recent American Gastroenterological Association, American College of Gastroenterology, and Canadian guidelines on the management of acute pancreatitis. Individual charts were reviewed and the following data were extracted: laboratory values, imaging results, dates of admission and discharge, interventions/procedures performed, antibiotic use, and nutrition. A total of 110 patients were included in the study. Mean age was 52 years (range, 16–92 years) and 58 (53%) patients were male. The most common cause of acute pancreatitis was gallstone (29%), followed by idiopathic (28%) and alcohol (20%). The mean Charlson comorbidity index was 2.2 (±2.7). Mean length of stay was 6.8 days (range, 1–84 days). Eight patients required intensive care unit admission. Ultrasound was performed within 48 hours of admission in 64 (58%) patients, and 43 (39%) patients had a computed tomography scan during their admission. The most common reason for computed tomography was diagnostic evaluation (35%), followed by investigation for underlying etiology (21%). Nineteen percent of patients did not obtain any imaging during their admission. Twenty-three (21%) patients did not receive any nutrition within their first 24 hours of admission. Antibiotic prophylaxis was started in 11 (10%) patients. Mean fluid resuscitation rate in the first 24 hours was 111 (±66) mL/h. Only 7 (6%) patients received fluid resuscitation, at a rate of >250 mL/h in the first 24 hours. No patients had appropriate laboratory values drawn to calculate Acute Physiologic Assessment and Chronic Health Evaluation score or other severity index scores. Only 12 (11%) patients had C-reactive protein measured. For patients with biliary pancreatitis, 24 (81%) underwent endoscopic retrograde cholangiopancreatography during their admission, and only 53% of those underwent cholecystectomy within the same admission. The management of patients presenting with acute pancreatitis remains quite variable, even at a large tertiary care center with expertise in pancreaticobiliary endoscopy. The most common areas of deficiency relate to imaging for potential etiologies, risk stratification, under-resuscitation with intravenous fluids, and delay to cholecystectomy, which we intend to target through a multifaceted quality improvement initiative.