TAP IN 24 – Are we performing an ascitic tap in patients presenting with decompensated liver disease and ascites within 24 hours of admission?

Quality Improvement Poster Download

Background & Problem

Decompensated liver disease is a common presentation with a high inpatient mortality (10-20%).1 The 2013 NCEPOD report highlighted that the management of these patients was suboptimal.2 Early intervention for complications of cirrhosis can save lives. One of the most serious complications is spontaneous bacterial peritonitis (SBP). Untreated, this carries a mortality of 90%, which falls to 20% with prompt recognition and treatment.3

The key investigation in diagnosing SBP is an ascitic tap; one of the items listed within the ‘Decompensated Cirrhosis Care Bundle – First 24 Hours’. Released by the British Society of Gastroenterology and the British Association for the Study of the Liver, the bundle helps to ensure that necessary investigations and appropriate treatments are initiated without delay.

There is an apparent lack of awareness of the need to perform this procedure within 24 hours in this group of patients and of the care bundle’s existence.

Aim

70% of patients presenting with ascites and decompensated liver disease will have an ascitic tap within the first 24 hours of admission by March 2017 in Gloucester Royal Hospital.

Method

Quality improvement tools including a driver diagram and fishbone analysis were used to study the problem and generate change ideas. Initial retrospective data collection was undertaken to establish baseline data. For the first PDSA cycle, change was introduced in the format of a practical teaching session amongst junior doctors on ACUA, demonstrating how to perform an ascitic tap and increasing awareness of the safety concern.

Results

'Analysis of patient referrals to Gastroenterology from September 2016-January 2017 showed a 42.9% success rate of an ascitic tap being performed within 24 hours of admission. Prospective data collection over February-March 2017, following the educational change intervention, shows a 55.6% success rate. The second data set involves a smaller sample size but indicates improvement.'

Implications

There is much further scope for this project. The educational element of the PDSA cycle was well received, but could be scaled up to a lecture in Foundation/Core Medical local teaching for example. The next most logical change idea, also suggested in feedback, is to make the care bundle available on the trust intranet treatment guidelines and place paper copies in ACUA.

1 British Society of Gastroenterology. ‘Decompensated Cirrhosis Care Bundle – First 24 Hours’ [internet]; [cited 23rd March 2017].
2 National Confidential Enquiry into Patient Outcome and Death. ‘Alcohol related liver disease: Measuring the units (2013)’ [internet]; [cited 23rd March 2017]. Available from: http://www.ncepod.org.uk/2013arld.html
3 Rawson TM, Bouri S, Allen C, Ferreira-Martins J, Yusuf A, Stafford N et al. Improving the management of spontaneous bacterial peritonitis in cirrhotic patients: assessment of an intervention in trainee doctors. Clinical Medicine. 2015; 15: 426