Introduction The Lancet standing commission on liver disease recently highlighted the importance of palliative care in advanced liver disease. The end of life care strategy (DoH, 2008) noted many patients do not die in a place of their choosing, and that difficulties exist amongst physicians in identifying the dying process. Optimal provision and co-ordination of palliative care relies on timely recognition of poor prognosis. 90% of patients who die from liver disease are admitted to hospital at least once in the previous year. Hospital admission presents an important opportunity to assess prognosis and explore patients’ understanding of their risk of dying and preferences for care. This quality improvement project aimed to create a clinical framework through which screening for poor prognosis could be integrated into the routine inpatient management of patients with decompensated cirrhosis.
Methods An inpatient Poor Prognosis Screening Tool (PPST - incorporating assessment of disease severity, WHO performance status, frequency of admission, and suitability for transplantation) was developed at University Hospitals Bristol in 2013. Based on retrospective data, a positive PPST screen predicted death at 1 year with a sensitivity of 81%. Initial audit identified infrequent use of the existing PPST (18.1%). A series of 5 quality improvement cycles (plan-do-study-act) were completed with input from consultants, junior medical and nursing staff at each stage. Ease of use and incorporation into routine practice were used as primary objectives.
Results The weekly ward MDT was identified as a point where the PPST could be routinely incorporated. Following feedback from junior staff the PPST was simplified and embedded into a weekly written MDT proforma. Guidance for completion were streamlined and made accessible by printing on the reverse of the proforma. Following feedback from nursing staff the proforma sheet was coloured, allowing key discussions and decisions to be easily identified on subsequent admissions. Consultants chairing the MDT incorporated the PPST into the standard weekly discussion of each patient. Repeat audits demonstrated that PPST use had become routine with completion rates of 66–94% for patients with decompensated cirrhosis.
Conclusion Assuming MDT agreement, a positive PPST screen triggers a consultant led poor prognosis discussion with the patient, a poor prognosis letter to the GP, and involvement of the palliative medicine team to assist with symptom control and advance care planning. Through incorporation of the PPST into the routine care of patients with decompensation, identification of patients with end-stage disease has improved. Better access to appropriate services and support, and improved co-ordination of community care can be subsequently afforded to appropriate patients.
Disclosure of Interest None Declared