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‘Care bundles’ improve managed care for hospitalized patients with cirrhosis

Recent findings indicated a connection between the implementation of a ‘care bundle’ and increased diagnostic paracentesis and antibiotic prophylaxis in patients hospitalized with decompensated cirrhosis, further suggesting the care bundle could improve overall managed care for these patients.

Only 47% of patients who died of alcohol-related liver disease received good care while hospitalized, according to a 2013 report from the UK National Confidential Enquiry into Patient Outcome and Death. Therefore, the group recommended the use of a toolkit to properly care for these patients. Based on that recommendation, J. K. Dyson, of Newcastle upon Tyne Hospitals NHS Foundation Trust and Institute of Cellular Medicine, Newcastle University, U.K., and colleagues developed a care bundle to ensure patients with chronic liver disease admitted to hospital began effective evidence-based treatments within 24 hours of admittance.

“It comprises a simple checklist to ensure important initial investigations are conducted,” the researchers wrote. “In addition, the bundle provides specific ‘step-by-step’ guidance on the management of infections … so that evidence-based treatments are delivered in a timely fashion, when specialist input may not be available.”

The researchers introduced the bundle at three National Health Service Hospital Trusts in the U.K., including Newcastle upon Tyne Hospitals NHS Foundation Trust, and followed up on patient care before and after implementation. They evaluated data collected from 228 patients (median age, 53 years). The main etiology of chronic liver disease was alcohol-related liver disease, found in 85% of patients, and 89% of all patients had known chronic liver disease. The overall mortality rate during hospital admission was 15%.

Reports of data from all three hospitals showed significant improvement in patient care for patients with a completed care bundle; they were more likely to have a diagnostic ascetic performed within the first 24 hours of admission (P = .02), have proper, accurate alcohol history documented (P < .0001) and receive antibiotics as prophylaxis against infection following a variceal hemorrhage (P = .0096).

“Patients who had a care bundle completed were more likely to have the appropriate investigations and management conducted than patients admitted prior to the introduction of the care bundle and those who did not have one completed,” the researchers wrote.

After introduction of the care bundle at Newcastle, the bundle completion rate was low (25%) upon first review. However, it increased to 90% by the third review period, according to the research.

“Our experience of introducing the bundle in these hospitals indicates that it can take time for a change to become embedded in clinical practice,” the researchers wrote.

They concluded: “If used more widely, a decompensated cirrhosis care bundle might reduce variability in the management of decompensated cirrhosis and ensure that life-saving evidence-based treatments are given early.” – by Melinda Stevens

Disclosure: Dyson is supported by the NIHR Newcastle Biomedical Research Center. Please see the study for a list of all other researchers’ relevant financial disclosures.