Improving the management of spontaneous bacterial peritonitis in cirrhotic patients: assessment of an intervention in trainee doctors

Rawson, Timothy M; Bouri, Sonia; Allen, Chris; Ferreira-Martins, João; Yusuf, Abulkani; Stafford, Nina; Pitcher, Maxton; Meron, Jacyna

doi:10.7861/clinmedicine.15-5-426

Cited by 10 publications

(10 citation statements)

References 9 publications

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“…With the elimination of access or cost of care as reason for low HAV and HBV vaccination rates, this QI project focused on provider education at the centre to raise awareness that HS is regarded as a CLD that necessitates HAV and HBV screening and health maintenance through vaccination. We recognise that educational interventions can be short lived for a variety of reasons such as turnover of staff and fellows . Therefore, we complimented education intervention with modifications to the EMR and patient education material that are affixed to the exam rooms.…”

Section: Discussionmentioning

confidence: 99%

“…We recognise that educational interventions can be short lived for a variety of reasons such as turnover of staff and fellows. 4 Therefore, we complimented education intervention with modifications to the EMR and patient education material that are affixed to the exam rooms. The goal was to change the practicing culture of the entire organisation more so than the practice of any one provider, so that the behaviour can be carried forward despite staff turnover.…”

Section: Discussionmentioning

confidence: 99%

“…The incidence of NAFLD is rising because of the increasing prevalence of type 2 diabetes mellitus (DM) and obesity with a global prevalence of approximately 30% . It is the leading cause of chronic liver disease (CLD) in the Western world . Patients with NAFLD have higher mortality compared to the general population with cardiovascular disease as the most common cause of death .…”

Section: Introductionmentioning

confidence: 99%

“…1,2 It is the leading cause of chronic liver disease (CLD) in the Western world. [3][4][5][6] Patients with NAFLD have higher mortality compared to the general population with cardiovascular disease as the most common cause of death. 7,8 Furthermore, patients with NASH may develop progressive fibrosis, leading to cirrhosis and hepatocellular carcinoma (HCC).…”

Section: Introductionmentioning

confidence: 99%

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HAV and HBV vaccination rates among biopsy‐confirmed NAFL patients in a free access medical system: How can we improve?

et al. 2020

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Summary Background Non‐alcoholic fatty liver (NAFL) is accounting for an increased proportion of chronic liver disease (CLD). These patients have higher risk of complications after acute hepatitis A (HAV) or hepatitis B (HBV) infections, but studies have demonstrated low immunisation rates. Aims To assess HAV and HBV vaccination rates within a free access treatment facility among those with liver biopsy‐confirmed NAFL and implement quality improvement (QI) measures. Methods About 371 pre‐QI and 212 post‐QI cohort liver biopsies were examined for quality measures (QM): (a) whether vaccination status was assessed, (b) whether subjects had immunity and (c) whether appropriate recommendation for immunisation was made. QI measures were implemented across two post‐QI plan‐do‐study‐act (PDSA) cycles including: (a) patient‐focused posters; (b) formal presentations to providers; and (c) incorporating HAV/HBV immunisation into the electronic medical record (EMR). Results For HBV vaccination, in the pre‐QI cohort, 96% met QM#1, 34% met QM#2 and 9% met QM#3. In the first post‐QI cycle, 97% met QM#1, 30% met QM#2 and 30% met QM#3. In the second post‐QI cycle, 97% met QM#1, 37% met QM#2 and 85% met QM#3. For HAV vaccination, in the pre‐QI cohort, 25% met QM#1, 20% met QM#2 and 6% met QM#3. In the first post‐QI cycle, 31% met QM#1, 25% met QM#2 and 21% met QM#3. In the second post‐QI cycle, 52% met QM#1, 42% met QM#2 and 85% met QM#3. Conclusion Patients with NAFL have low vaccination rates despite having access to free healthcare. Educating patients and both primary care and subspecialty providers on hepatitis vaccination is important and effective.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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HAV and HBV vaccination rates among biopsy‐confirmed NAFL patients in a free access medical system: How can we improve?

et al. 2020

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“…Few QI programmes have targeted EP in hospitalised patients with cirrhosis and none within 12 hours of presentation. Published interventions have included educational programmes targeting members of the admitting team or co-management with a specialist 12 13. However, inpatients increasingly spend extensive time in the ED secondary to hospital overcrowding and subsequent boarding of admitted patients 14 15.…”

Section: Introductionmentioning

confidence: 99%

Quality improvement initiative increases total paracentesis and early paracentesis rates in hospitalised cirrhotics with ascites

Jesudian

Barraza

Steel

et al. 2019

Frontline Gastroenterol

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ObjectiveEarly paracentesis (EP) for rapid diagnosis of spontaneous bacterial peritonitis is considered best practice in the care of admitted patients with cirrhosis and ascites, but inpatient paracentesis is frequently not performed or delayed. We developed a quality improvement (QI) initiative aimed at increasing the proportion of admitted patients with cirrhosis who undergo paracentesis and EP.Design Pre–post study of a QI initiative.Setting A tertiary care hospital in a major metropolitan area.Patients Hospitalised patients with cirrhosis and ascites.InterventionsWe targeted care providers in the emergency department (ED) by raising awareness of the importance of EP, developing criteria to identify patients at highest risk of SBP who were prioritised for EP by ED providers and restructuring the ED environment to enable timely paracentesis.Results76 patients meeting inclusion criteria were admitted during the postintervention 9-month study period. Of these, 91% (69/76) underwent paracentesis during admission versus 71 % (77/109) preintervention (p=0.001). 81% (56/69) underwent EP within 12 hours of presentation or after a predefined acceptable reason for delay versus 48% (37/77) preintervention (p=0.001). There were no significant differences in in-hospital mortality or length of stay before and after intervention.ConclusionA multidisciplinary QI intervention targeting care in the ED successfully increased the proportion of patients with cirrhosis and ascites undergoing diagnostic paracentesis during admission and EP within 12 hours of presentation.

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Identifying Quality Gaps in Preventive Care for Outpatients With Cirrhosis Within a Large, Academic Health Care System

et al. 2020

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We sought to identify specific gaps in preventive care provided to outpatients with cirrhosis and to determine factors associated with high quality of care (QOC), to guide quality improvement efforts. Outpatients with cirrhosis who received care at a large, academic tertiary health care system in the United States were included. Twelve quality indicators (QIs), including preventive care processes for ascites, esophageal varices, hepatic encephalopathy, hepatocellular carcinoma (HCC), and general cirrhosis care, were measured. QI pass rates were calculated as the proportion of patients eligible for a QI who received that QI during the study period. We performed logistic regression to determine predictors of high QOC (≥ 75% of eligible QIs) and receipt of HCC surveillance. Of the 439 patients, the median age was 63 years, 59% were male, and 19% were Hispanic. The median Model for End-Stage Liver Disease-Sodium score was 11, 64% were compensated, and 32% had hepatitis C virus. QI pass rates varied by individual QIs, but were overall low. For example, 24% received appropriate HCC surveillance, 32% received an index endoscopy for varices screening, and 21% received secondary prophylaxis for spontaneous bacterial peritonitis. In multivariable analyses, Asian race (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.3-10.2) was associated with higher QOC, and both Asian race (OR: 3.3, 95% CI: 1.2-9.0) and decompensated status (OR: 2.1, 95% CI: 1.1-4.2) were associated with receipt of HCC surveillance. A greater number of specialty care visits was not associated with higher QOC. Conclusion: Receipt of outpatient preventive cirrhosis QIs was variable and overall low in a diverse cohort of patients with cirrhosis. Variation in care by race/ethnicity and illness trajectory should prompt further inquiry into identifying modifiable factors to standardize care delivery and to improve QOC. (Hepatology Communications 2020;0:1-10). C irrhosis is a common condition associated with significant morbidity and mortality. (1,2) It is the twelfth leading cause of death in the United States (3) and carries a burden of disease that is projected to increase over the next decade due to a rising incidence of alcohol-associated liver disease and nonalcoholic steatohepatitis (NASH). (4,5) Cirrhosis is also associated with significantly decreased quality

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Improving the management of spontaneous bacterial peritonitis in cirrhotic patients: assessment of an intervention in trainee doctors

Cited by 10 publications

References 9 publications

HAV and HBV vaccination rates among biopsy‐confirmed NAFL patients in a free access medical system: How can we improve?

HAV and HBV vaccination rates among biopsy‐confirmed NAFL patients in a free access medical system: How can we improve?

Quality improvement initiative increases total paracentesis and early paracentesis rates in hospitalised cirrhotics with ascites

Identifying Quality Gaps in Preventive Care for Outpatients With Cirrhosis Within a Large, Academic Health Care System

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