Introduction Hospital admissions and mortality for patients with cirrhosis are rising. The acute management of patients with alcohol related liver disease (ARLD) was the subject of a NCEPOD report in 2013: ‘Measuring the Units’. This highlighted areas of management which could dramatically enhance care of this patient cohort and thus prevent the onset of multi organ dysfunction, so often the precursor to a poor outcome. In response to this BASL have released a detailed checklist for use in the acute setting: ‘Decompensated Cirrhosis Care Bundle – First 24 Hours’.
We undertook a local service review of all patients presenting to our unit with decompensated cirrhosis and evaluated their care using the clinical priorities highlighted by NCEPOD. We then adapted these core principles to create a novel clinical ‘memory tool’ designed to facilitate education and improve the acute medical care provided by generalists.
Method All admissions recorded as ‘cirrhosis’ from Aug 2013 – Aug 2014 were identified through clinical coding. Case notes and biochemical data were then reviewed according to the core NCEPOD principles.
Results 152 admissions were identified. Readmissions accounted for 39%. 26 patients were identified as having been admitted with a first ‘index’ presentation of decompensated ARLD (median age 61, 76% male). Nine (35%) were admitted to ITU. Hospital mortality was 50% (13/26). In those who died median Child Pugh (11 vs 9, p < 0.05) and UKELD (68 vs 58, p < 0.05) were higher.
On admission all patients had U&E’s; blood cultures were undertaken in 53%; ascites was present in 57% however only 45% of these had an ascitic tap. 38% saw a dietician within 48 h. 53% were seen by a gastroenterologist within 24 h and 50% were admitted to a specialist ward. A senior decision on care escalation was made in 98%.
In response to this problem the authors have developed a novel memory tool to facilitate a comprehensive approach to the acute management of these patients.
“RING Liver” focuses management on:
- R enal function
- I nfection
- N utrition
- G I bleeding/transit
The ‘Liver’ prompt encourages the user to consider the specifics of disease scoring systems, transplant candidacy etc. This tool has since been published in the national journal of acute medicine and been presented at teaching sessions to medical students, foundation, core and specialty medical trainees with unanimously positive feedback.
Conclusion With rising numbers of cirrhosis patients presenting to our acute medical units it is imperative that we ‘upskill’ receiving clinicians to ensure that early management is robust and places a memorable ‘RING’ of care around the patient.
Disclosure of interest None Declared.
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