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Abstract
Introduction Decompensated chronic liver disease (DCLD) is a medical emergency with high mortality, usually managed by non-specialists in emergency (ED) and acute medical (AMU) departments in critical early stages.
A recently introduced BSG/BASL care bundle1 (CB) highlights crucial investigations, which can influence outcome if performed early (<6 hr).
We audited performance against CB recommendations and impact on outcome.
Methods Data was reviewed retrospectively using electronic records. Adherence to 4 key CB investigations (blood tests/cultures, ultrasound (US) and ascitic tap in <6 hr) was logged, plus arrival/admission time and outcome (length of stay – LOS; readmission rate, mortality).
Results All patients admitted over 3 months with DCLD were included (n = 25 patients/33 total AMU admissions). Ascites (51.5%) and jaundice (24.2%) were the commonest presenting complaints. Most (57.6%) had Childs C disease (Childs A 6%; B 36.4%). LOS was variable (mean 11 days; median 7 [1–60]), and 7 people were readmitted within 1 month. In-patient mortality was 16% (12.1% of admissions) in keeping with national data, and 80% were alive at 3 months.
No-one had all 4 investigations performed within 6 hr of admission. 81.8% had routine blood tests performed (usually by ED), but only 15.1% had blood cultures, despite early identification of sepsis being a critical aspect of DCLD care. All cultures were taken for other reasons (e.g. cellulitis, pyrexia/rigour) suggesting sepsis risk in DCLD is under-appreciated by non-specialists.
39.4% had US requested within 6 hr and there was a lack of awareness of hepatoma/venous thrombosis as DCLD precipitants.
Just 24.1% of those with ascites had a diagnostic tap within 6 hr, with most not performed until under gastroenterology care. Data suggests this was due to inexperience of the admitting doctor, both in understanding importance of excluding/treating sepsis early, and technical capability to perform the test.
Slow patient flow added considerable delay to assessment/investigation, with 35% arriving in AMU > 6 hr post ED arrival (mean 4.5; median 5.5 [0.3–16 hr]), closing the window of opportunity for early intervention. There was a non-significant trend towards long waits in those who subsequently died (mean 7.5 hr; median 5.9 [3.6–14.5]), but no correlation between delay and LOS.
Conclusion Patients with DCLD were under-investigated and experienced considerable delay in assessment and investigation, possibly impacting mortality.
CB awareness was limited, and we identified failure of non-specialists to appreciate causes of DCLD and importance of rapid and robust assessment, compounded by delays in patient flow.
We arranged talks for AMU staff on DCLD, and have commenced enhanced gastroenterology in-reach for ED/AMU, to identify and treat patients more rapidly.
Disclosure of Interest None Declared