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

BACKGROUND

Since 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.

AIM

To 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.

METHODS

This 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.

RESULTS

Data 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.

CONCLUSIONS

The introduction of a care bundle was associated with increased rates of diagnostic paracentesis and antibiotic prophylaxis with variceal haemorrhage in patients with decompensated cirrhosis.

Validity of segmental transit studies used in routine clinical practice, to characterize defaecatory disorder in patients with functional constipation

OBJECTIVE

Segmental colonic transit can be determined by performing regional counts of radio-opaque markers on an abdominal radiograph. It has been claimed that the pattern of markers can be used to characterize the type of constipation, with a concentration of markers seen in the rectosigmoid region in patients with defaecatory disorders. The aim of our study was to examine this hypothesis in a cohort of patients with functional constipation.

METHOD

Consecutive patients presenting to a specialist constipation clinic and satisfying inclusion criteria were studied. All patients had the following assessments: radio-opaque marker study performed according to a standard protocol; proforma-based symptom assessment using Likert scoring; and radioisotope defaecating proctogram. Transit study data included total transit time, rectosigmoid transit time and geometric mean of markers. Symptom scores were recorded for straining, incomplete evacuation and digitation, together with a cumulative symptom score. Evidence of outlet obstruction from the proctogram included four previously described parameters.

RESULTS

A total of 108 patients with functional constipation according to the Rome criteria with a median age of 41 years were studied. Neither rectosigmoid transit time nor the geometric centre of markers could differentiate patients with a functional defaecatory disorder (FDD). There was no correlation between the pattern of marker distribution and any of the parameters denoting outlet obstruction.

CONCLUSION

Our data do not support the hypothesis that assessment of segmental transit, using standard methods applicable to routine clinical practice can determine the type of constipation. In particular, patients exhibiting evidence of FDD are no more likely to have recto-sigmoid retention of markers than those without.

Blinded comparison of faecal loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation

AIM

To compare faecal loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation.

METHODS

The study group was a convenience sample of patients attending the Durham Constipation Clinic. All patients underwent transit studies according to an established protocol, and severity of constipation was assessed contemporaneously using a validated questionnaire (PAC-SYM). Transit studies were performed using radio-opaque markers that were ingested over 3 consecutive days, with a radiograph taken on the fourth day. Digital images of the radiograph were digitally altered to remove all traces of the transit markers without affecting the underlying pattern of faecal loading. Four observers assessed faecal loading independently; two clinicians (C1 and C2) and two radiologists (R1 and R2). C1 and R1 used a previously described formal scoring method of assessing faecal loading, whereas C2 and R2 assessed the images as if they were in a clinic or reporting session, grading the faecal loading as mild, moderate, or severe.

RESULTS

One hundred patients were recruited out of 186 presenting in a 2-year period. All patients completed assessments. The correlation between observers was only fair to moderate (r ranging from 0.34-0.51). There were some surprisingly marked disagreements in 10-18% of assessments. The correlation between faecal loading and transit was weak for all observers (r ranging from 0.261-0.311). Symptom severity did not correlate with faecal loading.

CONCLUSION

These results suggest that there is considerable inter-observer variation in the radiological assessment of faecal loading, irrespective of the training or method used by the observer, and that there is very poor correlation with colonic transit. The diagnosis of constipation, and the assessment of severity, is best performed clinically.