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Decompensated cirrhosis: targeted training of acute medical teams to improve quality of care in first 24 hours

24 November 2022
Volume 31 · Issue 21



A quality improvement project in a secondary care centre was initiated to investigate and evaluate the impact of staff education and the use of the British Society of Gastroenterology/British Association for the Study of the Liver cirrhosis care bundle in improving care of patients admitted to hospital with decompensated liver cirrhosis.


A staff training programme was implemented, involving around 30 health professionals consisting of consultants, junior doctors, physician associates and nurses from the acute medical unit. A review of electronic documentation and analysis of key clinical parameters, pre- and post-intervention, was carried out.


The data show that the intervention has led to an improvement in patient management and clinical outcomes.


This project illustrates that collaboration between hepatology and medical teams, with emphasis on education and training, benefits patients who present to hospital with decompensated liver cirrhosis.

Liver cirrhosis is characterised by a silent, asymptomatic course, often referred to as ‘compensated cirrhosis’ (Ballinger, 2012; Angeli et al, 2018). The hallmark of advanced disease is the development of portal hypertension, which manifests in patients as ascites, variceal bleeding, hepatic encephalopathy and jaundice (Porth, 2011). This is termed decompensated liver cirrhosis and is associated with higher mortality when compared with patients who are still in the compensated stage (Porth, 2011; Ballinger, 2012; Harrison, 2015).

The main causes of liver cirrhosis in the UK are alcohol-related liver disease (ARLD), viral hepatitis (B and C) and non-alcohol-related fatty liver disease (NAFLD) (British Association for the Study of the Liver (BASL) and British Society of Gastroenterology (BSG), 2009; Williams et al, 2014). Recent studies and national mortality alerts have identified rates of liver disease to be steadily increasing in the UK over the last two decades and is ranked as the fifth most common cause of death in the UK (Williams et al, 2014; Harrison, 2015; British Liver Trust, 2019). It is a silent killer as most people with liver disease do not have obvious symptoms until the disease is at an advanced stage. In most cases, the chances of successfully managing it are slim as there are limited options for management in the later phase of the disease (BASL, 2009; Williams et al, 2014; British Liver Trust, 2019). Among all digestive diseases, liver disease was reported to be the second leading cause of death in the UK and USA (Everhart, 2008; British Liver Trust, 2019) and has been highlighted by the World Health Organization (2022) as the leading cause of death among digestive diseases. Furthermore, there is an increase in liver-related hospital admissions, which is associated with a high mortality rate. The National Confidential Enquiry into Patient Outcome and Death (2013) report on patients with ARLD, Measuring the Units, found significant variations in the management of patients admitted with complications of liver cirrhosis. The review highlighted various avoidable factors that might have contributed to patients' death. Although the review only looked at patients with ARLD, it is plausible that the findings would be similar for other aetiologies too. Based on this report and its recommendations, BSG and BASL (2019) devised a ‘care bundle’, which is widely available. This details a step-by-step management guide for patients admitted to hospital with decompensated cirrhosis, with key interventions to be made within the first 24 hours of admission.

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