A novel, nurse-led ‘one stop’ clinic for patients with liver cirrhosis results in fewer liver-related unplanned readmissions and improved survival

Abstract

Objective Delivering effective secondary preventive and integrated care has the potential to break the revolving-door phenomenon of frequent readmissions in patients with advanced chronic liver disease. To address this, we launched the Care Coordination of Liver Disease (CCoLD) pilot, a novel nurse-led cirrhosis clinic in Western Sydney. Methods and analysis Following an index presentation to Blacktown or Mount Druitt hospitals (BMDH), patients (n = 89, matched by age, sex, and MELD-NA) were consecutively either followed up by the CCoLD clinical nurse consultant (intervention cohort) or received standard care (control cohort). Controlled evaluation of the impact of the nurse-led clinic was carried out for a 3-month period including readmission rates, survival, and cost effectiveness. Results The inaugural nurse-led clinic led to improvement in patient-level outcomes including a reduction in unplanned liver-related readmissions (2.08% for intervention cohort vs 12.2% for control cohort, p < 0.01), and mortality at 30 days (0% for intervention cohort vs 7.3% for control cohort, p = 0.03). Similar trends were observed at 90 days from index discharge. No deaths were observed in the intervention cohort as compared to the control cohort at 90 days (0% versus 7.3%, p = 0.03), while unplanned liver-related readmissions were 10.41% for the intervention cohort vs 19.5% for the control cohort (p = 0.115). Moreover, time to readmission was significantly longer in the intervention cohort, resulting in an overall cost-effective intervention. Conclusion These findings highlight the significant impact of optimised care-coordination. A nurse-led clinic can deliver patient-centred, goal-directed, and cost-effective secondary prevention and care. A multicentre randomised trial for wider evaluation of these findings is warranted.

Inpatient management of fluid overload (ascites, hepatic hydrothorax, and anasarca)

“…[4,9] Posthospitalization follow-up with a dedicated cirrhosis nurse has been shown in a small trial to be associated with lower 30-day readmissions and 90-day mortality. [15]…”

“…Outpatient visits with a dietician are also important to reinforce adherence to goal sodium, protein, and caloric intake 4,9 . Posthospitalization follow-up with a dedicated cirrhosis nurse has been shown in a small trial to be associated with lower 30-day readmissions and 90-day mortality 15 …”

Hospitalized patients with cirrhosis: Addressing gaps in care

“…To overcome the knowledge gap due to time restrains and difficulty for hospital practitioners to keep up to date with the latest guidelines, many QI trials have used easy-to-access and time-efficient tools to reduce variation in clinical practice: handheld checklists, 16 templated notes, 17 best practice alerts/decision support, 16 and clinical pathways/order sets 18,19 . More resource-intensive solutions have addressed institutional logistics and culture changes but require high commitment across all shareholders: “best practice” in emergency room focusing on timely interventions, 20 dedicated teams to perform emergency room or inpatient paracentesis, 21 bundled interventions to ensure timely performance of diagnostic paracentesis (education + workflow support/ultrasound/premade kits + alert + orderset) 22 or postdischarge care management programs 23,24 …”

“…[18,19] More resource-intensive solutions have addressed institutional logistics and culture changes but require high commitment across all shareholders: "best practice" in emergency room focusing on timely interventions, [20] dedicated teams to perform emergency room or inpatient paracentesis, [21] bundled interventions to ensure timely performance of diagnostic paracentesis (education + workflow support/ultrasound/premade kits + alert + orderset) [22] or postdischarge care management programs. [23,24] Despite the increase in compliance with practice guidelines, the results of QI initiatives have varied in terms of sustainability and impact on clinical outcomes (survival, length of stay, and readmissions), sometimes leading to undesired effects (increased length of stay due to electrolyte disturbances secondary to excessive lactulose use). [19] Nevertheless, they provide useful ideas that should be tailored to the local institutional needs and practices.…”