P-218 Using Quality Improvement to Increase Utilization of Enteral Therapy in Pediatric Crohn Disease

Abstract

Background: Enteral nutrition therapy (EN) is safe and effective for induction of remission in Crohn's disease (CD) but is underutilized in the United States due to multiple perceived barriers. We implemented a protocol to initiate and overcome barriers related to EN. We hypothesized that implementing this protocol using a quality improvement-based approach would increase utilization of EN and induce remission of CD. Method(s): In July 2013, we developed and implemented an algorithm for administration of EN. Tools were developed for providers to effectively discuss EN with patients and families, initiate the correct amount of formula, record use, and document medical necessity. Dietitians provided follow -up and providers assessed response. For induction of remission, children were given polymeric formula meeting 90% to 100% of their caloric requirements over a 12-week period. To assess improvement in utilization, we compared the average number of patients per month who were prescribed EN before and after implementing the protocol. Clinical outcomes were assessed for children =21 years with active CD and no history of prior intestinal resection that completed a minimum of 8 of the 12 weeks of EN between July 2013 and May 2015. The short pediatric Crohn's disease activity index (sPCDAI), body mass index (BMI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, and hemoglobin were compared before and after induction with EN. Result(s): Between July 2013 and May 2015, 65 patients with CD started EN; 5 were excluded because of inactive disease and three were lost to follow up. Of the 57 remaining patients (mean age 12.7 +/- 2.9 years, 49% female, 86% white), 40 (70%) had ileocolonic disease and eleven (19%) had perianal phenotype. EN was started within four weeks of diagnosis for 42 (74%) patients. Average calories were 1798 (6348) or 90.2% of estimated caloric requirements. The average number of patients starting EN increased from 0.6 patients per month before to 3.4 after implementing the protocol (560% increase). Of the 57 patients who started EN, 24 (44%) both completed at least 8 weeks of treatment and achieved remission. Of the 29 who completed at least 8 weeks of EN and had follow up data, 24 (83%) achieved remission. In these patients, there was a significant reduction of sPCDAI (33 +/- 15.7 to 9.5 +/- 11.6, P 0.0001) and ESR (27 +/- 17 to 17 +/- 10, P 0.001) and an increase in albumin (4 +/- 0.5 to 4.2 +/- 0.4, P 0.05). Changes in BMI, CRP, and hemoglobin were not statistically significant. Twenty-five children (44%) were unable to complete induction and finished an average of 4.3 weeks (+/- 2). Twelve patients (48%) cited inability to drink the formula, 14 (56%) had inadequate response, and 4 (16%) stopped because of a complication of CD. Adverse events were reported in 25 patients (44%) including nausea, vomiting, diarrhea, and bloating. Conclusion(s): Systematic implementation of tools designed to increase utilization of EN is effective in overcoming perceived barriers and increasing the acceptance of primary enteral therapy. Remission was successfully achieved in children who completed induction therapy with EN.