Background/Purpose: Henoch-Schönlein Purpura (HScP) is the most common form of vasculitis in children, with gastrointestinal (GI) complaints occurring in more than a third of patients within one week of symptom onset. Patients may require hospitalization for pain control, intravenous hydration, bowel rest and parenteral nutrition, and disease monitoring for intestinal intussusception and bowel perforation. Reintroducing enteral nutrition during the period of active intestinal vasculitis can be challenging and may result in recurrence of abdominal symptoms and lead to readmission. No established pediatric dietary recommendations exist for HScP. We sought to improve non pharmacologic management by implementing a quality improvement initiative with the goal of reducing 30-day readmission rates by half in the first 12 months of intervention. Our aim was to provide diet recommendation to all patients admitted with HScP with a pediatric rheumatology consult.

Methods: We retrospectively reviewed the medical records of 20 HScP patients with GI involvement who were admitted in 2015 to determine that the 30-day readmission rate was 50%. Review of inpatient management had been similar with inclusion of glucocorticoids, bowel rest for severe involvement, and optimal fluid and electrolyte therapy. There was, however, variability in the dietary management of these patients. Specific diet recommendations were created by a group of hospital dietitians and pediatric rheumatologists. These recommendations were based on providers’ own observations combined with knowledge about diets low in acid, complex carbohydrates, and fats that are predicted to result in less gastrointestinal distress and better absorption. We also took into consideration dietary modifications recommended for patients with inflammatory bowel disease. Three HScP diet stages were created to facilitate diet advancement and were instituted using specific comments in the electronic diet orders. Smart phrases were created for the consistency of the dietary advice. All patients were seen by dietitian for patient and parental education.

Results: A total of 36 patients at Texas Children’s Hospital had a pediatric rheumatology consult for management of HScP with GI involvement between 2017 to 2019. We found that the 30-day readmission rate was reduced to 25% in 2017, 17% in 2018, and 25% in 2019. Our goal was achieved in the first 12 months with similar outcomes in the subsequent 24 months of the diet implementation. All rheumatology attendings and fellows adhered to dietary intervention as part of initial and follow up consult recommendations.

Conclusion: Our dietary intervention showed a reduction in the 30-day readmission rates. Due to lack of evidence, the creation of the HScP diet required collaboration across dietitians, rheumatologist, patients, families, and food service. Future directions include additional modifications to the diet to increase patient compliance, simplify electronic diet orders, and continue education among dietitians and pediatric hospital providers. Our ultimate goal is to design a hospital admission order set with best practice alerts to standardize the dietary intervention.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/impact-of-a-nutrition-focused-quality-improvement-intervention-on-hospital-readmission-rates-in-henoch-schonlein-purpura-with-gastrointestinal-involvement/