PTU-105 “i can’t give iv fluids, the patient has ascites!”: improving the management of acute decompensated cirrhosis at a district general hospital

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Abstract

Introduction

The National Confidential Enquiry into Patient Outcomes and Deaths report in 2014 found patients with acute decompensated cirrhosis (ADC) were more likely to receive suboptimal care when initially reviewed by a non-specialist. Poor management, such as inadequate fluid resuscitation, can be catastrophic, as noted locally. We sought to improve this through targeted education and use of the British Society of Gastroenterology’s (BSG) “liver care bundle”.

Method

Patients admitted to our hospital with ADC between March and September 2015 were identified by the coding department. A retrospective audit was performed using hospital notes and electronic data. Demographic information, such as length of stay (LOS) and readmissions, was collected, along with clinical management details as outlined by the BSG bundle, which was our standard of care.

Method

From September 2015, a gastroenterology registrar led case-based interactive lectures for all junior doctor groups and performed ad hoc ward teaching. This covered the pathophysiology of ADC, the rationale for specific management strategies and how to perform ascitic taps. They were strongly encouraged to use the liver bundle.

Method

Prospective data was obtained from September 2015 to March 2016 for all patients admitted with ADC. Each individual admission was counted separately.

Results

Between March and September 2015, there were 33 admissions, compared to 30 in the subsequent six months. No bundles were filed pre-intervention. Post-intervention, it was completed 28/30 times (93%) overall, and within six hours of admission – as the BSG advises – 14/30 times (47%).

Results

The performance within all measured domains improved or remained at 100%. For example, ascitic tap was done in 20/28 patients with ascites (71%) before and in 20/22 patients (91%) after, blood culturing increased from 5/33 (15%) to 22/30 (73%) and abdominal ultrasounds rose from 11/33 (33%) to 29/30 (97%).

Results

Mean LOS increased from 6.4 to 7.6 days, mainly, it seems, for social reasons, with no change in mortality (10%–20%). However, the number of readmissions reduced.

Results

Pre-intervention, there were 16 readmissions, compared to 6 post-intervention. Five patients were readmitted at least twice before, but none after.

Conclusion

Focussed education and use of the BSG liver bundle can improve the care of patients with ADC. Whilst mortality remained within the national incidence, readmission rates reduced substantially. This may reflect more thorough diagnosis and treatment, so patients are clinically better on discharge. This is also financially beneficial for the Trust, which pays for readmissions rather than the Clinical Commissioning Group. Similar projects across the country could improve the management of these vulnerable patients.

Disclosure of Interest

None Declared

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