title: Severe acute pancreatitis in the community: confusion reigns.
abstract: BACKGROUND
  The management of acute pancreatitis (AP) has evolved through enhanced understanding of the disease. Despite several evidence-based practice guidelines for AP, our hypothesis is that many hospitals still use historical treatments rather than adhere to the current guidelines, which have demonstrated shorter hospital stays, decreased infectious complications, decreased morbidity, and decreased mortality.
  
  
  METHODS
  Seventy-eight patients transferred to our institution with AP from 2010-2014 were retrospectively studied to compare pretransfer versus posttransfer adherence to current practice guidelines. Primary measures included use of antibiotics (abx), enteral nutrition, drainage of asymptomatic pseudocysts, and interventions for necrosis in the early phase (<4 wk).
  
  
  RESULTS
  Pretransfer, abx were given to 51 patients; however, posttransfer, abx were discontinued in 33 patients and started in 6 patients within 24 h of admission (pretransfer versus posttransfer abx, 51 versus 24, P < 0.001). Empiric abx for AP were used in 36 patients pretransfer versus 9 patients posttransfer (P < 0.001). Patients were initially nil per os or on total parenteral nutrition in 89%; this was reduced to 17% within 72 h by starting a diet or enteric feeds (pretransfer versus posttransfer feeding, 9 versus 65 patients, P < 0.001). Fifteen transfer patients had pseudocysts that were believed to "require drainage"; five patients received intervention but >4 wk from initial episode of AP. Pretransfer, five patients had pancreatic debridement in the early phase, which resulted in prolonged postoperative length of stay compared with eight patients requiring debridement, which were delayed (early versus late, 56 versus 16 d, P < 0.05).
  
  
  CONCLUSIONS
  There is still great confusion in the treatment of AP in community hospitals. Primary principles in the care of these patients are not routinely followed despite established guidelines. Increased dissemination is required to prevent lengthy hospitalizations and long-term morbidity.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California. Electronic address: mdua@stanford.edu.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Dua
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: David J
authors.initials: DJ
authors.lastname: Worhunsky
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Thuy B
authors.initials: TB
authors.lastname: Tran
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Rowza T
authors.initials: RT
authors.lastname: Rumma
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: George A
authors.initials: GA
authors.lastname: Poultsides
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Norton
authors.affiliation: Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: Walter G
authors.initials: WG
authors.lastname: Park
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Brendan C
authors.initials: BC
authors.lastname: Visser
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D002140:California; D003131:Combined Modality Therapy; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006764:Hospitals, Community / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000628:therapy*; D010360:Patient Transfer; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies
keywords: Acute pancreatitis; Antibiotics; Necrosectomy; Nutrition; Practice guidelines