Introduction: Pediatric acute liver failure (PALF) is a rapidly progressive disorder with significant morbidity and mortality. Given the wide differential for PALF, systematic and age-based diagnostic approach is recommended. Using quality improvement (QI) methodology, we aimed to develop an age-based, tiered diagnostic order set for PALF patients upon initial admission to our center.

Method: We employed the Plan-Do-Study-Act (PDSA) framework to design our PALF order set. The gastroenterology (GI) department received education about the new order set prior to launch. A retrospective chart review was conducted for patients meeting PALF criteria up to two years before implementation and compared with patients admitted after implementation. Our primary endpoint was completeness of work-up. Secondary outcomes included presence of a diagnosis, survival with native liver, liver transplantation, or death.

Results: 24 patients met criteria for analysis pre-order set implementation, and 9 patients met criteria in the 3 months following implementation. The average completeness of first-tier work-up was 56.4% pre-implementation and 58.9% post-implementation. 33.3% of patients had ≥75% completeness of first tier work-up post-implementation as compared to 16.7% pre-implementation. 88.9% of patients post-implementation attained a diagnosis, and 77.8% had survival with native liver compared to 62.5% diagnosis rate and 58% survival with native liver pre-implementation. 

Conclusion: While overall completeness of first tier work-up remained similar, a higher percentage of patients achieved ≥75% completion post-implementation compared to pre-order set implementation. Future PDSA cycles will focus on refining the order set, incorporating feedback, and expanding education to non-GI teams to further improve care for PALF patients.