Quality Improvement Boosts Use of Enteral Therapy in Patients With Crohn’s Disease

Quality Improvement Boosts Use of Enteral Therapy in Patients With Crohn’s Disease 1024 575 Kevin Mayhood
Color image of enteral complete liquid nutritional products of several brands

Refined procedures, tools and support promote this proven alternative to steroids.

A team of researchers found that employing quality-improvement methods increased use of exclusive enteral nutrition (EEN) to induce remission in children with Crohn’s disease at Nationwide Children’s Hospital.

By increasing awareness of the therapy, standardizing procedures and providing support, EEN usage increased from less than 5 percent of children newly diagnosed with Crohn’s to 50 percent.

Half of those who started the treatment completed therapy. Among them, 71 percent achieved remission.

“Exclusive enteral nutrition is recommended but rarely ever used because people feel patients just won’t do it,” says Wallace Crandall, MD, medical director of Quality and director of the Center for Pediatric and Adolescent Inflammatory Bowel Disease at Nationwide Children’s and senior author of the study.

In order to induce remission of intestinal tract inflammation caused by Crohn’s, EEN limits a patient’s diet to commercial liquid formulas for two months or more.

“The perceived barriers to usage were not insurmountable problems,” says Dr. Crandall, who is also a professor of Clinical Pediatrics at The Ohio State University College of Medicine. “If you design a system to support it, EEN can be done quite well.”

The research team of physicians, nurses and nutritionists was motivated by the fact EEN’s efficacy is equal to medications’ but without their risk for infections and cancer. Their study is in the Journal of Gastroenterology and Nutrition.

“Our goal was to make prescribing this therapy as easy as writing a prescription for steroids,” says Ala Shaikhkhalil, MD, an attending pediatric gastroenterologist and physician specialist in nutrition at Nationwide Children’s and lead author. “It’s not, but we addressed multiple barriers one by one so that the process is not overwhelming.”

Key steps included creating an algorithm that defines how to apply EEN and when to assess, and constantly fine-tuning it to get the best outcome.

When the team rolled out the algorithm, dieticians were to meet with each family within a week of initiating EEN. But dietitians quickly took the requirement several steps further, talking with families and providing details about the process and benefits of EEN at the same time the provider was offering the therapy, or talking to patients and family by phone before they scheduled a meeting, or to follow-up.

“They made themselves available anytime; their passion really was a driver,” says Dr. Shaikhkhalil, an assistant professor of Clinical Pediatrics at The Ohio State University College of Medicine.

The team drafted a guide to initiating EEN by age and gender and templates for obtaining insurer’s approval for the therapy and responding to denials. The researchers also drafted scripts for talking with patients and their families, referring to EEN as nutritional therapy and formula as nutrition shakes. Then, they educated providers in conferences and one-on-one conversations. They followed-up when the provider failed to use EEN and took steps to remove the barriers.

The algorithm and all the tools were developed through Plan-Do-Study-Act cycling.

Another key to the improvement is this generation of parents and patients appears to be ripe for EEN, Dr. Shaikhkhalil says. “Parents and patients are likely to want to explore the role of diet in the treatment of Crohn’s disease and when informed of the success of this therapy, welcome EEN as an alternative to steroids.”

The EEN program was applied to 73 newly diagnosed children. The mean age was between 12 and 13.  Of the 73, 37 completed at least 8 weeks of EEN and 25 achieved remission.

The researchers are now studying how to make EEN easier for patients, especially how to help patients complete therapy so that they can benefit.


Shaikhkhalil A, Boyle B, Smith J, Dotson JL, Donegan A, Kim SC, Maltz RM, Crandall W. Using quality improvement to increase utilization of enteral therapy in pediatric Crohn disease: Results and outcomesJournal of Pediatric Gastroenterology and Nutrition. 2018 Jan 6. [Epub ahead of print]

Photo credit: Nationwide Children’s Hospital

About the author