Background Patients hospitalised with decompensated cirrhosis (jaundice, variceal bleeding, ascites or hepatic encephalopathy) have high rates of early, unplanned readmission, associated with increased complications and healthcare costs. Optimising preventative care reduces readmissions but many patients are readmitted before their outpatient review by hepatologists. Consequently, we established a novel care pathway with a nurse-led, structured early post-discharge clinic. Patients are seen within 2 weeks of discharge, with specific interventions for ascites, encephalopathy, varices, alcohol misuse and nutrition. The aim of our study was to assess impact on readmission and mortality.

Methods Following an index admission with decompensated cirrhosis, patients were seen in the nurse-led, early post-discharge clinic (intervention cohort) or received standard hepatology physician-led outpatient follow up (controls). Clinical data including demographics, liver disease aetiology, reason for admission and stage of liver disease were analysed. Outcome measures included time to first readmission, rate of readmissions and mortality up to 12 months.

Results There were 91 control patients and 78 in the intervention cohort. There were no significant differences in age, gender or aetiology of liver disease at index admission and mean MELD-Na on discharge was 18.1 and 19.8 (p=NS) in control and intervention groups respectively. Ascites was the most common decompensating event in both groups. Median time to readmission was 51 days in the control group and 98 days in the intervention group (p<0.01). The intervention cohort had significantly fewer early readmissions at 30 days (12% versus 30%, p<0.01) and 90 days (27% versus 49%, p<0.01) but not significantly at 12 months (58% versus 68%, p=0.16) with an overall reduction in bed day usage of 33%. Mortality for the control group was 4% at 30 days with no deaths in the intervention group. There were fewer deaths in the intervention group at 90 days (5% versus 15%, p<0.05) and 12 months (22% versus 41%, p<0.01).

Conclusions Following an index hospitalisation with decompensated cirrhosis, goal-directed early post-discharge care can be effectively delivered by specialist nurses, prior to outpatient review by hepatologists. This model was associated with significantly fewer unplanned readmissions, lower bed day usage and a reduced mortality. Our data suggest such nurse-led models of care deserve wider implementation and further evaluation.