Standard Order Set for Admitted Patients with Hepatitis A
Patients with hepatitis A should be admitted to a general medical ward with appropriate isolation precautions, with management focusing on supportive care, monitoring for complications, and preventing transmission to others. 1
Admission and Initial Workup
- Place patient on enteric precautions for the first two weeks of illness and one week after the onset of jaundice 2
- Obtain comprehensive liver function tests including ALT, AST, bilirubin (total and direct), alkaline phosphatase, GGT, albumin, and prothrombin time 1
- Order specific viral hepatitis markers to confirm diagnosis: anti-HAV IgM (acute infection) 1
- Perform abdominal ultrasound to assess liver architecture and rule out biliary obstruction 1
- Obtain baseline complete blood count, basic metabolic panel, and coagulation studies (PT/INR) 1, 3
- Monitor coagulation factors, particularly prothrombin time and factor V levels, to assess for risk of fulminant hepatic failure 3
Isolation Precautions
- Implement standard precautions plus enteric precautions 4, 2
- Ensure patient has dedicated bathroom facilities or bedpan/urinal 2
- Require handwashing before and after patient contact 1, 2
- Use gloves when handling feces, urine, or blood 2
- Provide patient with dedicated eating utensils and dishes 2
Supportive Care
- Provide adequate hydration with IV fluids if patient has significant nausea/vomiting or is unable to maintain oral intake 5, 6
- Administer antiemetics as needed for nausea and vomiting 5
- Ensure adequate nutrition with small, frequent meals if tolerated 5
- Monitor for signs of hepatic encephalopathy (confusion, asterixis, altered mental status) 3
- Avoid hepatotoxic medications including acetaminophen, NSAIDs, and alcohol 5, 6
- Provide rest and symptomatic relief for constitutional symptoms 5
Monitoring
- Check vital signs every 4 hours, including temperature to monitor for fever 1
- Monitor liver function tests daily until improving 1, 3
- Assess mental status every shift to detect early signs of encephalopathy 3
- Monitor intake and output 1
- Assess for signs of dehydration 5
- Monitor for complications including cholestatic hepatitis, relapsing hepatitis, or fulminant hepatic failure 3, 6
Risk Assessment and Public Health Measures
- Obtain detailed history of risk factors, including recent travel, food exposure, and close contacts 1
- Report case to appropriate public health authority 7
- Initiate epidemiologic investigation in collaboration with public health authorities to identify source of infection and contacts who might have been exposed 7
- Identify close contacts who should receive post-exposure prophylaxis 7
Post-Exposure Prophylaxis for Contacts
- Administer hepatitis A vaccine to previously unvaccinated close contacts within 2 weeks of exposure 7
- Consider immune globulin (IG) for contacts who are immunocompromised, have chronic liver disease, or are >40 years old 7
- For household contacts, sexual contacts, and those sharing illicit drugs with the patient, provide hepatitis A vaccine or IG within 2 weeks of exposure 7
Discharge Planning
- Educate patient about disease transmission and prevention 1
- Advise patient to avoid preparing food for others until 1 week after jaundice onset 6
- Recommend hepatitis B vaccination for patients with chronic liver disease who are not already immune 8
- Arrange follow-up appointment to monitor for complete resolution and potential relapse 5, 6
- Provide guidance on avoiding alcohol for at least 6 months 5
Special Considerations
- For patients with signs of fulminant hepatic failure (encephalopathy, coagulopathy), consider transfer to a liver transplant center 3
- For pregnant patients, ensure close monitoring as risk of complications may be higher 7
- For patients with underlying chronic liver disease, monitor more closely for decompensation 8