PTU-113 Implementing the decompensated cirrhosis care bundle in a district general hospital

• Published in: Gut Vol. 67; no. Suppl 1; p. A246
• Main Authors: Lee, Phey Shen, Broad, Andrea, Grapes, Allison, Pecqueur, Jessica, Brown, Fraser
• Format: Journal Article
• Language: English
• Published: 01.06.2018
• ISSN: 0017-5749; 1468-3288
• DOI: 10.1136/gutjnl-2018-BSGAbstracts.491

IntroductionThe Decompensated Cirrhosis Care Bundle was published by McPherson et al (BMJ 2014) in response to the 2013 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report into deaths from alcoholic liver disease. We describe our experience in implementing this at a district general hospital.MethodsThe care bundle checklist was used as basis for audit pre-implementation in September 2014, post-implementation in June 2015 and re-audit in September-October 2016. Patients were identified via ICD codes, with review of electronic records and case notes.ImplementationThe care bundle was made available on our trust intranet. We launched it with education sessions for medical and nursing staff in the Emergency Care Centre.The AUDIT-C tool was embedded into the VitalPAC electronic observations system to ensure all patients were assessed for alcohol use. A ‘Decompensated Cirrhosis’ blood test panel was added to our electronic requesting system. Magnesium was added to calcium and phosphate under ‘bone profile’.ResultsBaseline results pre-implementation were comparable to regional data. Post-implementation results showed significant improvements which were sustained a year later (figures 1 and 2). 70%–80% of patients were reviewed by a gastroenterologist within 24 hours, improving from 44%.Abstract PTU-113 Figure 1Basic investigations within first 6 hours of admissionAbstract PTU-113 Figure 2Performance indicators for management of decompensated cirrhosisWe achieved the 100% target for sepsis management and investigating precipitants of hepatic encephalopathy. All patients with SBP received antibiotics and albumin.GI bleeders were only identified in the third cycle; all variceal bleeds. They were all adequately resuscitated and underwent timely endoscopy. Only 40% received both terlipressin and antibiotics.Venous thromboembolism (VTE) prophylaxis prescription showed no improvements in latter cycles compared to the first. Management of alcohol withdrawal showed a slight decline in both cycles.ConclusionsIntroduction of the care bundle led to clear improvements in the initial assessment (blood tests, ascitic tap and abdominal ultrasound), management of encephalopathy and timely specialist input. These were sustained, albeit with room for improvement. We believe that using IT and involving nursing staff in assessment areas have helped to embed these improvements.Sepsis was recognised and treated appropriately in 100% of audited patients. This may reflect concomitant sepsis awareness campaigns.We were less successful with prescribing for VTE prophylaxis, alcohol withdrawal and variceal bleeds. This may reflect turnover of junior doctors and system factors, including patient flow and availability of specialty cover on ‘base wards’ (not 7 days). Our education programme needs to be ongoing. We propose incorporating the care bundle into our Junior Doctors’ Handbook.