Introduction The 2013 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report ‘Measuring the Units’¹and a regional audit²suggested significant deficiencies in the management of patients with decompensated liver disease. As a result, on behalf of the BSG and BASL, we developed a ‘care bundle’ to optimise and standardise the care of patients with decompensated liver disease in the first 24 h.³Our aim was to audit the implementation of the care bundle in our Trust.

Method A retrospective audit was conducted on the management of consecutive patients admitted with decompensated liver disease to our general medical admissions unit over 4 time periods (1 pre- and 3 post-introduction of the care bundle) to assess the effect of bundle implementation. Direct admissions to the tertiary liver unit were excluded as twice daily consultant ward rounds might confound results for those patients.

Results Since the care bundle was introduced in March 2014, there has been a significant stepwise increase in completion rates (6/25 (24%) for Jun/Jul 14; 5/11 (36%) for Nov 14 and 7/8 (88%) for Dec 14/Jan 15). Table 1shows a comparison of patient management prior to bundle implementation and post-implementation in those with and without a completed bundle. Overall, patients with a completed care bundle were more likely to have appropriate management compared with patients pre-implementation and subjects post-implementation without a completed bundle. The most striking improvement was in performing a diagnostic tap to exclude spontaneous bacterial peritonitis (SBP) which increased to 100% in patients with a completed bundle compared with 46% in those without a bundle completed (p = 0.008).

Conclusion Uptake of the care bundle was initially slow, but with perseverance completion rates have increased from 24% to 88% over 9 months. The ‘care bundle’ appears to improve patient care, particularly by increasing the proportion of patients having a diagnostic ascitic tap. Ongoing audit will assess the impact of the care bundle on other aspects, such as management of variceal haemorrhage, length of hospital stay and mortality.

Disclosure of interest None Declared.

References

1. http://www.ncepod.org.uk/2013arld.htm

2. Dyson, et al. PTU-113. BSG, 2014

3. McPherson, et al. Frontline Gastroenterol. 2014 doi:10.1136/flgastro-2014-100491