Background: In the United States, chronic hepatitis C is the leading cause of liver transplantation, and there are more than 3.5 million people infected with hepatitis C virus. Liver fibrosis evaluation is the most important assessment because individuals with hepatitis C are predisposed to liver fibrosis and liver failure. Individuals with advanced fibrosis and cirrhosis are at increased risk of developing advanced liver disease related complications such as variceal bleeding and hepatocellular carcinoma. Therefore, early recognition of these patients and providing recommended imaging surveillance for hepatocellular carcinoma, and gastroesophageal varices are imperative in reducing negative outcomes. Local problem: In an inner-city infectious disease clinic, more than 30% of patients with hepatitis C did not have complete evaluation for liver fibrosis. The lack of liver fibrosis staging can potentially lead to negative clinical outcomes, such as cirrhosis, liver failure and hepatocellular carcinoma. Hence, the purpose of this quality improvement project was to increase the completion rate of liver fibrosis staging for adult patients with chronic hepatitis C in an outpatient infectious disease clinic.
Intervention: A quality improvement project was developed to improve and standardize liver fibrosis evaluation through the implementation of electronic order set in the electronic medical record. Following education on the evidence-based components of the order set, provider compliance was monitored through electronic reports to determine whether the completion rate of liver fibrosis evaluation for patients with chronic hepatitis C increased.
Result: The implementation of the electronic order set was effective in increasing the fibrosis evaluation completion rate. Before order set implementation, 68.7% of patients had complete fibrosis evaluation as compared with 89.7% after order set implementation (p= 0.016). Conclusion: The implementation of an evidence-based hepatitis C order set improved liver fibrosis staging completion rates by more than 20%, and improved patient clinical outcomes by reaching evidence-based treatment goals for patients with hepatitis C. Electronic order sets are a sustainable method to implement evidence-based practice guidelines, and to ensure standardization of practice across all providers in a facility.