S1409 Improving Provider Adherence to Nutritional and Metabolic Recommendations in Patients With Acute Alcoholic Hepatitis: A Quality Improvement Initiative

Abstract

Introduction: Alcoholic hepatitis (AH) is an acute, inflammatory liver disease associated with high morbidity and mortality, both short and long term. Current medical therapy for severe alcoholic hepatitis relies on corticosteroids, which have modest efficacy. Alcohol abstinence is of critical importance but recidivism is high. Efficacious medical treatments for alcoholic hepatitis are lacking. Preliminary and Preclinical studies include use of Antibiotics, IL-1 inhibitors, GCSF and antioxidants. Malnutrition and sarcopenia are common among hospitalized AH patients with negative impact on outcome.[1] Current guidelines generally recommend daily protein intake of 1.2–1.5 g/kg/day and caloric intake of 30- 40 kcal/kg/day in alcoholic hepatitis patients. [2][3] Our objective is to implement methods to facilitate adherence to nutritional recommendations in hospitalized patients with AH. Methods: We conducted a 12-month retrospective study followed by a 3-month prospective interventional study at Presbyterian Medical Center. Chart review was performed to evaluate adherence with nutritional recommendations in patients with AH. A 3-month intervention was performed to improve compliance. This included the creation of a customized best practice advisory alert (BPA) in the Electronic medical record (EMR). The triggers included elevated ALT/AST, bilirubin >3 and documented alcohol use within 8 weeks. Alert encouraged physicians to request a nutrition consult if the diagnosis of AH was appropriate. Results: 105 patients with 82 in the pre- and 23 post-intervention periods were reviewed. No significant difference in patient characteristics and demographics was noted between the 2 groups. The intervention implemented revealed a 79% increase in adherence to nutritional recommendation (P < 0.023). Adherence was quantified as modified diet orders in EMR to include high protein diet ( minimum of 60 grams/daily ) and/or addition of supplemental high protein milk shakes to meals and/or electronic consult to nutritionist. Conclusion: AH has high morbidity and mortality. Current pharmacological options remain limited. Patients with AH are commonly malnourished and sarcopenic. System based auto-generated EMR alerts help increase compliance with the nutritional recommendations as well as enforce evidence-based practices in this select patient population.