Implementation of a ‘care bundle’ improves the management of patients admitted to hospital with decompensated cirrhosis

Abstract

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.

Editorial: improving in‐hospital management of decompensated cirrhosis by a ‘care bundle’ – hope, frustration and lessons to learn. Authors’ reply

“…We thank Professor Bosch for his editorial on our paper describing the outcomes of implementation of a ‘care bundle’ for the management of patients admitted with decompensated cirrhosis in three hospitals in the UK . Overall, we would argue that there is more ‘hope’ than ‘frustration’ as introduction of the care bundle was shown to improve the completion of key investigations and delivery of evidence based treatments within the first 24 h. Although we were not able to demonstrate that use of the care bundle had an impact on mortality, the sample size was relatively small and there were differences in the patient characteristics (see Table ) between the three patient groups, which means they may not be directly comparable from a mortality risk perspective.…”

Cost‐effectiveness of integrating gut microbiota analysis into hospitalisation prediction in cirrhosis

“…Therefore, these data are valid for US‐based patients, and may not be generalisable elsewhere. Given that a large percentage of cirrhosis patient cohorts are hospitalised, we combined the admission and readmission endpoint in the 90‐day window to make this applicable to most patients . However, the cost of individual hospitalisations to the healthcare system, regardless of first admission or a readmission, is largely similar.…”

“…Given that a large percentage of cirrhosis patient cohorts are hospitalised, we combined the admission and readmission endpoint in the 90-day window to make this applicable to most patients. 6,38,39 However, the cost of individual hospitalisations to the healthcare system, regardless of first admission or a readmission, is largely similar. Therefore, we did not further analyse the effect on ICU transfer and length of stay but used the average cost of each admission.…”

Management of decompensated cirrhosis

“…5,6 A multicentre review in three English hospitals found that use of this care bundle improved all aspects of care and can help ensure patients with decompensated cirrhosis receive optimum management early in their hospital admission. 7 …”