Secondary Logo

Institutional members access full text with Ovid®

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

Results and Outcomes

Shaikhkhalil, Ala K.; Boyle, Brendan; Smith, Jennifer; Dotson, Jennifer L.; Donegan, Amy; Kim, Sandra C.; Maltz, Ross M.; Crandall, Wallace

Journal of Pediatric Gastroenterology and Nutrition: June 2018 - Volume 66 - Issue 6 - p 909–914
doi: 10.1097/MPG.0000000000001879
Original Articles: Gastroenterology: Inflammatory Bowel Disease

Introduction: Exclusive enteral nutrition (EEN) for induction of remission in children with Crohn disease (CD) is recommended as first-line therapy, but underutilized in the United States related to real and perceived barriers. We hypothesized that quality improvement (QI) methodology could increase use of EEN.

Methods: We developed, implemented, and revised an algorithm and a set of tools to facilitate use of EEN. Through a series of Plan Do Study Act cycles, the approach was modified to overcome provider and patient/family barriers. The primary outcome, the percentage of newly diagnosed CD patients who receive EEN per month between July 2013 and October 2015, assessed using statistical process control. Secondary outcomes, including the short pediatric Crohn disease activity index (sPCDAI), body mass index (BMI) z score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, and hemoglobin were compared before and after EEN.

Results: Among patients newly diagnosed with CD, 73 patients initiated EEN and were included (mean age 12.7 ± 2.9 years, 49% girls, 86% white). Rates of utilization of EEN increased significantly from a baseline of <5% to an average of approximately 50%. Of the 73 patients who started EEN, 37 (50%) completed a minimum of 8 weeks. Of those completing therapy, 25 (71%) achieved remission, with a significant reduction of sPCDAI (33.6 ± 14.4 to 10.7 ± 12.3, P < 0.0001)

Conclusions: Use of QI methodology to systematically implement tools designed to improve utilization was effective in increasing the use of EEN. Among those completing therapy, EEN was effective in inducing remission.

Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH.

Address correspondence and reprint requests to Ala K. Shaikhkhalil, MD, Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, 700 Children's Drive Columbus, OH 43205 (e-mail:

Received 29 March, 2017

Accepted 18 December, 2017

The authors report no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (

© 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,