Improving the management of decompensated liver cirrhosis in the first 24 hours of admission

Quality Improvement Poster Download

Background & Problems

Decompensated liver cirrhosis is a common acute medical emergency with a high morbidity and mortality rate. The NCEPOD (National Confidential enquiry into patient outcome and death) report in 2015 revealed that, nationally, we are not recognising common causes of acute liver failure in this patient group, e.g. sepsis and dehydration. The British Society of Gastroenterology (BSG) created a bundle to help perform the initial investigation and management in these patients and the main aim was to implement this within Gloucestershire Royal Hospital. There are multiple areas of this bundle but we specifically wanted to improve the timing of the correct blood tests and X-rays on admission.

Aim

To increase the number of initial investigations from a baseline of 40% to 93% in 6 months.

Method

We initially performed a baseline audit, where only 40% of patients had all the correct initial investigations performed within 24 hours of admission. We implemented the bundle on yellow paper and performed teaching to both ED and AMU to increase awareness. Teaching was also done to nursing staff (who are the continuity). We also changed the e-referral system to ensure a mandatory box was ticked to make sure it was done. These changes were done via 3 PDSA cycles and data collected on a monthly basis.

Results

We made a small improvement over the 3 PDSA cycles, with the change in the e-referral one being the largest. However, on the run chart, there is quite a lot of variety in the system to be confident of this. Despite this, awareness has been increased and there is certainly more update from the junior doctors. It will still take a while to embed.

Implications

Implementing a bundle is difficult when the group who you want to use it don’t see the immediate benefit. Once encouraged, they junior doctors felt it was useful and you do need someone to encourage its use beyond the QI. The plan is to take this to the clinical governance meeting so more senior management can have more of a say in how we could implement this better. Process changes are more effective that teaching!