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A Learning Collaborative Approach Increases Specificity of Diagnosis of Acute Liver Failure in Pediatric Patients

2018; Elsevier BV; Volume: 16; Issue: 11 Linguagem: Inglês

10.1016/j.cgh.2018.04.050

1542-7714

Michael R. Narkewicz, Simon Horslen, Regina M. Hardison, Benjamin L. Shneider, Norberto Rodriguez‐Baez, Estella M. Alonso, Vicky L. Ng, Mike A. Leonis, Kathleen M. Loomes, David A. Rudnick, Philip Rosenthal, René Romero, Girish Subbarao, Ruosha Li, Steven H. Belle, Robert H. Squires, Robert H. Squires, Kathryn Bukauskas, Madeline Schulte, Michael R. Narkewicz, Michelle Hite, Kathleen M. Loomes, Elizabeth B. Rand, David A. Piccoli, Deborah A. Kawchak, Christa Seidman, René Romero, Saul J. Karpen, Liezl de la Cruz-Tracy, Vicky L. Ng, Kelsey Hunt, Girish Subbarao, Ann Klipsch, Sarah Munson, Estella M. Alonso, Lisa Sorenson, Susan Kelly, Katie Neighbors, Philip Rosenthal, Shannon Fleck, Mike A. Leonis, John C. Bucuvalas, Tracie Horning, Norberto Rodriguez Baez, Shirley Montanye, Martín Cowie, Simon Horslen, Karen F. Murray, Melissa Young, Heather Nielson, Jani Klein, David A. Rudnick, Ross W. Shepherd, Kathy Harris, Saul J. Karpen, Alejandro de la Torre, Dominic Dell Olio, Déirdre Kelly, Carla Lloyd, Steven J. Lobritto, Sumerah Bakhsh, Maureen M. Jonas, Scott A. Elifoson, Roshan Raza, Kathleen B. Schwarz, Wikrom Karnsakul, Mary Kay Alford, Anil Dhawan, Emer Fitzpatrick, Benjamin L. Shneider, Nanda Kerkar, Brandy Haydel, Sreevidya Narayanappa, M. James Lopez, Victoria Shieck, Edward Doo, Averell H. Sherker, Steven H. Belle,

Sepsis Diagnosis and Treatment

Background & Aims Many pediatric patients with acute liver failure (PALF) do not receive a specific diagnosis (such as herpes simplex virus or Wilson disease or fatty acid oxidation defects)—they are left with an indeterminate diagnosis and are more likely to undergo liver transplantation, which is contraindicated for some disorders. Strategies to facilitate complete diagnostic testing should increase identification of specific liver diseases and might reduce liver transplantation. We investigated whether performing recommended age-specific diagnostic tests (AS-DTs) at the time of hospital admission reduces the percentage PALFs with an indeterminate diagnosis. Methods We performed a multinational observational cohort study of 658 PALF participants in the United States and Canada, enrolled at 10 medical centers, during 3 study phases from December 1999 through December 2014. A learning collaborative approach was used to implement AS-DT using an electronic medical record admission order set at hospital admission in phase 3 of the study. Data from 10 study sites participating in all 3 phases were compared before (phases 1 and 2) and after (phase 3) diagnostic test recommendations were inserted into electronic medical record order sets. Results The percentage of subjects with an indeterminate diagnosis decreased significantly between phases 1–2 (48.0%) and phase 3 (to 30.8%) ( P = .0003). The 21-day cumulative incidence rates for liver transplantation were significantly different among phase 1 (34.6%), phase 2 (31.9%), and phase 3 (20.2%) ( P = .030). The 21-day cumulative incidence rates for death did not differ significantly among phase 1 (17.9%), phase 2 (11.9%), and phase 3 (11.3%) ( P = .20). Conclusions In a multinational study of children with acute liver failure, we found that incorporating diagnostic test recommendations into electronic medical record order sets accessed at time of admission reduced the percentage with an indeterminate diagnosis that may have reduced liver transplants without increasing mortality. Widespread use of this approach could significantly enhance care of acute liver failure in children.