Introduction Incidence of chronic liver disease (CLD) is increasing, related to both alcohol and obesity.1 Decompensated CLD is a medical emergency, carrying a mortality of 20%–70%2 requiring key interventions within the first 24 hours. In 2016, the BSG partnered with BASL to combat this trend with an evidence-based care bundle in response to 2013 NCEPOD report.3,4
Aim Using 2014 & 2016 data, we highlight the shortfalls in practice against the BSG/BASL care bundle in a large teaching hospital North West England.
Method Retrospective review of electronic patient records for acute admissions with decompensated liver disease, focusing on the first 24 hours of admission. We compared two separate data sets from 2014 (n=121) and 2016 (n=50). The data was audited against the seven domains of the care bundle: Investigations, Alcohol, Infections, Kidney Injury, UGIB, Encephalopathy and VTE prophylaxis.
Results In 2014, 19% (23/121) of patients presented with a suspected variceal UGIB. Of these, only 48% (11/23) received Terlipressin and 70% (16/23) received antibiotics. In 2016, the percentages were 26% (13/50), 92% (12/50) and 92% (12/50) respectively.
In 2014, 73% (88/121) patients presented with clinical ascites. 43% (38/88) of these patients had a diagnostic paracentesis attempted within 24 hours, of which 16% (6/38) attempts failed to aspirate ascites. In 2016, the percentages were 68% (34/50), 53% (18/34) and 22% (4/18) respectively.
In 2014, VTE prophylaxis was indicated but not prescribed in 48% (58/121) of patients, compared with 34% (16/47) in 2016.
Conclusion The BSG and BASL care bundle provides a clear and concise collection of achievable aims for the first 24 hours of admission for the decompensated liver patient. This data demonstrates clear improvement in pharmacological management of UGIB from 2014 to 2016, related to updated local guidance, but we are lagging behind with early diagnostic paracentesis analysis and VTE prophylaxis. Education and awareness are key to improving confidence in managing some of the sickest patients on the acute take. This is the initial step in the process of a QIPP to improve liver care in this teaching hospital, firstly by raising awareness of the shortfalls, secondly by elevating the profile of the care bundle and thirdly by educating all staff and empowering them to comply.
Williams R, et al. Implementation of the Lancet Standing Commission on Liver Disease in the UK. Lancet2015
Bernal W, et al. Acute-on-chronic liver failure. Lancet2015
NCEPOD. Alcohol related liver disease: measuring the units. 2013.
. BSG/BASL. Decompensated Cirrhosis care bundle – the first 24 hours. 2016.
Disclosure of Interest None Declared
- acute kidney injury
- alcohol misuse
- alcohol withdrawal
- Decompensated liver disease
- Hepatic Encepahlopathy
- hepatorenal syndrome
- liver care bundle
- Liver cirrhosis
- liver disease
- Liver Fibrosis
- Upper Gastrointestinal Bleeding
- Upper Gastrointestinal Haemorrhage
- variceal bleed