2026 Eastern States Conference

Title: Care bundle to improve outcomes for patients with hepatic encephalopathy
 
Authors: Emily Baraclough, PharmD, Deslynne Henkel, PharmD, Jennifer Szwak, PharmD, BCPS, FCCP; Madison McKnight, PharmD, BCPS; The Johns Hopkins Hospital, Department of Pharmacy, Baltimore, MD 

Learning Objective: Define current management practices and readmission rates for patients with hepatic encephalopathy at the Johns Hopkins Hospital (JHH).  

Background/Objective: Hepatic encephalopathy (HE) is associated with significant healthcare utilization and costs. This study aims to characterize the HE population and current readmission rates at JHH to later develop a consensus-driven care bundle to improve management and reduce readmissions. 

Methods: This quality improvement study includes two phases. First, a retrospective cohort analysis included adult patients admitted to JHH from 2022-2024 with a primary diagnosis of hepatic encephalopathy. This characterized demographics, disease severity, medication use, transitions-of-care practices, and 30- and 90- day readmissions. Patients receiving a liver transplant within 30 days of discharge or death within 30 days of discharge were excluded. Data was collected via the Precision Medicine Analytics Platform (PMAP), an electronic health record-derived database, and manual chart review. Descriptive statistics summarized baseline characteristics and care patterns, as well as readmission rates. A follow-up study will utilize a Delphi model with JHH hepatologists to achieve consensus on key interventions and develop a standardized care bundle. 

Results: A total of 221 patients were included in the study. Alcohol-related cirrhosis was the most common etiology (37.7%), followed by mixed etiologies (15.9%) and metabolic-associated cirrhosis (15.3%). The cohort was predominantly male (51.8%), with a mean age of 57.35 ± 12.96 years. The mean MELD score at the time of dialysis was 27.84 ± 6.22. Prior to admission, lactulose was prescribed in 31.82% of patients, while rifaximin was prescribed in 26.36%. Among patients not receiving rifaximin prior to admission, 27.3% had a prescription initiated at discharge, of whom 8.64% completed a prior authorization before discharge. The 30-day readmission rate was 17.2%, while the 90-day readmission rate was 27.1%. 

Conclusion: In this cohort of patients with cirrhosis and hepatic encephalopathy, variability in pre-admission use and discharge access to guideline-directed therapy was observed. Inconsistencies in rifaximin initiation and prior authorization completions highlight opportunities to optimize transitions of care and reduce readmissions through targeted interventions.