Providing a nurse-led service for patients with liver disease

The hepatology department at the Hull University Teaching Hospitals NHS Trust provides care and treatment for patients with liver disease to a local population of more than 600 000. Historically, this was delivered by medical staff. The service was audited to identify areas requiring development, with the aim of improving care for patients with liver disease and reduce length of hospital stay. The findings were categorised into inpatient, outpatient and day-case services.

Inpatient length of stay was often prolonged, and readmissions were frequent. Patients with ascites requiring drainage were only managed as an inpatient episode and had a median length of stay of 4.5 days. There was infrequent use of the British Society of Gastroenterology (BSG) and the British Association for the Study of the Liver (BASL) Decompensated Cirrhosis Care Bundle, which led to under-investigation and delays in care.

The lack of a dedicated hepatology in-reach service resulted in some patients not receiving any specialist input and were managed in non-specialist wards, contributing to increased lengths of stay and mortality.

Outpatient liver services were under pressure, with more than 750 new outpatient referrals each year. More than 650 patients with cirrhosis required hepatoma surveillance reviews twice a year, in addition to approximately 1000 patients receiving long-term follow-up. The waiting list backlog exceeded 100 patients per month, which particularly impacted the provision of timely hepatoma surveillance. A limited cirrhosis database existed, which consisted of approximately 200 patients; it was recognised that the actual number would be significantly higher and much work was required to identify these. The dedicated post-discharge liver clinic delivered by one consultant had reached capacity, resulting in challenges to see all liver-related discharges within the desired 2-week period.

In addition, the Trust did not have any day-case provision for liver patients, which impacted negatively on the quality of life for those suitable for day-case management.

In April 2018, a pilot scheme was established for a liver specialist nurse to lead on the following:

As a gastroenterology sister with an interest in liver disease and aspirations to become a liver specialist nurse, I took on this role to lead and implement this new service.

Daily nurse-led in-reach to the acute medical unit (AMU) and non-specialist wards enabled liver patients to be introduced to the service, undergo a specialist review, and develop an appropriate management plan with the aid of the cirrhosis care bundle. Patients were identified for transfer to the specialist gastroenterology ward, identified for early discharge with a rapid outpatient review, or for transfer to the new day-case paracentesis service.

Nurse-led surveillance clinics ensure that a 6-monthly review of all patients with cirrhosis are undertaken. Essential surveillance ultrasound scans and bloods are completed, in addition to a review of the patient's nutritional status, medications, alcohol history and their need for variceal surveillance. A physical examination is also carried out to check for complications such as ascites, jaundice, hepatic encephalopathy or any signs of gastrointestinal bleeding. Surveillance clinics also enable the liver specialist nurse to assess whether the patient requires referral to additional services, such as palliative care, addiction services, or a dietitian or consultant review. Clinics provide an opportunity to review the patient's individual management plan, and appointments may be scheduled more frequently to prevent hospital readmission. Surveillance dates are logged on a database, ensuring timely surveillance of patients with cirrhosis.

The liver specialist nurse also runs a post-discharge clinic for patients with liver disease, which complements the existing consultant clinic. The nurse monitors the patient's condition, carries out tests for further investigation or monitoring purposes, ensures follow-up with other services, books surveillance when required, and reinforces education. The patient may then be discharged, kept for further review or transferred to an alternative follow-up service, such as the cirrhosis surveillance clinic.

The nurse-led day-case paracentesis service started in May 2018 in the medical day unit. The service was designed to be flexible and suit patients' needs. A dedicated day-case document is used to ensure a seamless day-case pathway. The service manages a cohort of 15 to 20 patients and can accommodate a wide range of patients, including those on anticoagulants or those requiring ultrasound guidance. Reviews from other disciplines, such as dietitians and palliative care, may also take place on the same day.

Within all settings the liver specialist nurse provides patients with information including:

The liver specialist nurse also ensures that necessary referrals to additional services are made, ensures that any future appointments for tests are known to the patient, and reiterates the importance of ongoing follow-up for long-term health.

The new liver nurse service was promoted across the Trust via posters, the intranet, attending departmental and sisters' meetings, provision of education and training sessions for junior doctors, nurses and advanced care practitioners, in addition to walking the wards to introduce myself and offer support in caring for patients with liver disease.

No significant challenges or issues were identified in establishing the new service and other departments were very supportive, which reflected the need for change.

For each aspect of the service, positive outcomes resulted, these are detailed below.

The liver specialist nurse is now an integral part of hepatology reviews in the acute medical unit (AMU) and non-specialist wards. Reviews occur daily, with up to five patients reviewed per day. In addition, an internal audit of the use of the cirrhosis care bundle in 2018 showed that approximately 80% of patients with decompensated cirrhosis had been assessed using this checklist. This represents a considerable improvement in the use of the bundle.

Timely cirrhosis surveillance clinics are now delivered with no backlog of patients waiting for an appointment. Clinics are managed by the liver specialist nurse with the support of the administrative team. Investigations are often ordered in advance so that patients' results may be discussed on the day of the clinic. Approximately 80 patients are seen in the nurse-led cirrhosis surveillance clinics each month, which means that consultants are available for those patients requiring a consultant review. In addition, between October 2017 and October 2018, there has been an observed reduction in the average waiting time for cirrhosis surveillance clinics from 71 to 14 days.

The cirrhosis surveillance database is now more comprehensive because an increasing number of patients have been identified by the liver nurse. This occurred because medical staff copied clinic letters to the liver nurse, along with direct communication about specific patients. The database now includes more than 650 patients with cirrhosis.

With the support of the liver specialist nurse, the dedicated hepatology post-discharge clinic is better equipped to meet the demand for follow-up post discharge. Patients are prioritised for follow-up, and requested time frames range from 1 to 4 weeks post discharge.

Between December 2018 and September 2019, some 227 patients were seen in the liver discharge clinic, with an average time to follow-up of 4.9 days. Ninety-five (42%) were seen in the clinic and managed by the liver specialist nurse.

Between May 2018 and March 2019 the nurse-led paracentesis service demonstrated an average length of stay of 6 hours (range 2-9 hours), an approximate 94% reduction from the previously seen inpatient average of 4.5 days (range 0-22 days). Within the initial 12-month period, an approximate 440 inpatient bed days were saved, with an associated cost benefit in excess of £160 000. Other benefits of the day-case paracentesis service include reduced admissions to the emergency department because patients requiring paracentesis would often present there previously, a more robust diuretic tailoring and monitoring process for patients with ascites, and the reduction in the number of clinics the patients attend because surveillance, consultant and dietetic reviews may be carried out at the same time.

Within all aspects of the liver nurse service, excellent feedback has been received from patients, relatives and other health professionals.

Examples of feedback received from patients and relatives are as follows:

Examples of feedback from staff included::

Key outcomes and feedback obtained since the introduction of the new liver service were presented at the European Association for the Study of the Liver (EASL) International Liver Congress and the BASL annual conference in 2019. This has resulted in a number of requests for further information on setting up a similar service in the UK and across Europe. A case study is presented in Box 1.

Case study

John Walker (not his real name), a 71-year-old retired professional, developed cirrhosis secondary to primary sclerosing cholangitis and experienced recurrent ascites requiring drainage. He also had hepatic encephalopathy, atrial fibrillation (on anticoagulation) and had sarcopenia. A liver transplant was not an option because of his comorbidities, and he was classified as having end-stage liver disease. He was therefore referred to palliative care.

Between November 2017 and July 2018 Mr Walker had 13 ascitic drains, six of which were as inpatient episodes. His average length of stay was 4.3 days. During each hospital admission, he experienced drain-related hypotension, which required treatment and prolonged his stay. As a result, he became more anxious about readmission and experienced some depression.

After the introduction of the nurse-led day-case clinic in May to July 2018, Mr Walker had 7 day-case paracentesis appointments, which were arranged every 10 to 14 days, with an average length of stay of 6 hours. He had fewer clinic appointments because he could be reviewed by the consultant and palliative care team in the day unit.

Mr Walker passed away peacefully at home in August 2018. Based on his average length of stay, he gained 28 days at home in the last 3 months of his life as a result of the day-case service, an improvement on his previous inpatient experience.

I was pleased to be nominated and to be runner-up in the Hepatology/Liver Nurse of the Year category of the BJN Awards 2020.