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SummaryBackgroundSince 1970, there has been a 400% increase in liver‐related deaths due to the increasing prevalence of chronic liver disease in the United Kingdom (UK). The 2013 UK National Confidential Enquiry into Patient Outcome and Death report found that only 47% of patients who died from alcohol‐related liver disease received ‘good care’ during their hospital stay.AimTo develop a ‘care bundle’ for patients with decompensated cirrhosis, aiming to ensure that evidence‐based treatments are delivered within the first 24 h of hospital admission.MethodsThis work gives practical advice about how to implement the bundle and examines its effects on patient care at three National Health Service Hospital Trusts in the UK by collecting data on patient care before and after introduction of the bundle.ResultsData were collected on 228 patients across three centres (59% male, median age 53 years). Alcohol‐related liver disease was the aetiology of chronic liver disease in 85% of patients. The overall mortality rate during hospital admission was 15%. The audits demonstrated improvements in patient care for patients with a completed care bundle who were significantly more likely to have a diagnostic ascitic performed within the first 24 h (P = 0.020), have an accurate alcohol history documented (P < 0.0001) and be given antibiotics as prophylaxis against infection following a variceal haemorrhage (P = 0.0096). In Newcastle, the bundle completion rate increased from 25% to 90% during the review periods.ConclusionsThe introduction of a care bundle was associated with increased rates of diagnostic paracentesis and antibiotic prophylaxis with variceal haemorrhage in patients with decompensated cirrhosis.

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Pneumorrhachis: a rare complication of diabetic ketoacidosis FIGURE 2 Computerized tomography (CT) of the thorax confirming the presence of air in the soft tissues and pneumomediastinum and also revealing pneumorrhachis (air in the spinal canal).