Improved outcomes following the implementation of a decompensated cirrhosis discharge bundle

IntroductionMortality from liver disease is increasing and management of decompensated cirrhosis (DC) is inconsistent across the UK. Patients with DC have complex medical needs when discharged from hospital and early readmissions are common. Our aims were: (1) to develop a Decompensated Cirrhosis Discharge Bundle (DCDB) to optimise ongoing care and (2) evaluate the impact of the DCDB.MethodsA baseline review of the management of patients with DC was conducted in Newcastle in 2017. The DCCB was developed and implemented in 2018. Impact of the DCDB was evaluated in two cycles, first a paper version (November 2018–October 2019) and then an electronic version (November 2020–March 2021). Key clinical data were collected from the time of discharge.ResultsOverall, 192 patients (62% male; median age 55; median model for end-stage liver disease 17; 72% alcohol related) were reviewed in three cycles. At baseline, management was suboptimal, particularly ascites/diuretic management and provision of follow-up for alcohol misuse and 12% of patients had a potentially avoidable readmission within 30 days. After DCDB introduction, care improved across most domains, particularly electrolyte monitoring (p=0.012) and provision of community alcohol follow-up (p=0.026). Potentially preventable readmissions fell to 5% (p=0.055).ConclusionsUse of a care bundle for patients with DC can standardise care and improve patient management. If used more widely this could improve outcomes and reduce variability in care for patients with DC.

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Using rapid cycle tests of change to develop the Carers Assistive Technology Experience Questionnaire: a cognitive interview study in the UK

BMJ Open ◽

10.1136/bmjopen-2020-042361 ◽

2021 ◽

Vol 11 (3) ◽

pp. e042361

Author(s):

Vimal Sriram ◽

Crispin Jenkinson ◽

Michele Peters

Keyword(s):

Assistive Technology ◽

Cognitive Interview ◽

Electronic Version ◽

Cognitive Interviews ◽

Eligibility Criteria ◽

Paper Version ◽

Healthcare Settings ◽

Technology Experience ◽

The Uk ◽

Experience Questionnaire

We describe the use of rapid cycle tests of change to pretest and develop a Carers Assistive Technology Experience Questionnaire for a survey of informal carers of persons with dementia. The Plan-Do-Study-Act (PDSA) cycle is a commonly used improvement process in healthcare settings. We used this method for conducting rapid cycle tests of change through cognitive interviews to pretest the questionnaire. The items for the questionnaire were developed based on an earlier systematic review and qualitative study. PDSA cycles were used incrementally with learning from each cycle used to inform subsequent changes to the questionnaire prior to testing on the next participant.DesignQualitative with use of cognitive interviews through rapid cycle tests of change.SettingUK.ResultsNine participants were recruited based on eligibility criteria and purposive sampling. Cognitive interviewing using think aloud and concurrent verbal probing was used to test the comprehension, recall, decision and response choice of participants to the questionnaire. Seven PDSA cycles involving the participants helped identify problems with the questionnaire items, instructions, layout and grouping of items. Participants used a laptop, smartphone and/or tablet computer for testing the electronic version of the questionnaire and one participant also tested the paper version. A cumulative process of presenting items in the questionnaire, anticipating problems with specific items and learning from the unanticipated responses from participants through rapid cycle tests of change allowed rich learning and reflection to progressively improve the questionnaire.ConclusionUsing rapid cycle tests of change in the pretesting questionnaire phase of research provided a structure for conducting cognitive interviews. Learning and reflections from the rapid testing and revisions made to the questionnaire helped improve the process of reaching the final version of the questionnaire, that the authors were confident would measure what was intended, rapidly and with less respondent burden.

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COVID-19 in liver transplant candidates: pretransplant and post-transplant outcomes - an ELITA/ELTR multicentre cohort study

Gut ◽

10.1136/gutjnl-2021-324879 ◽

2021 ◽

pp. gutjnl-2021-324879

Author(s):

Luca Saverio Belli ◽

Christophe Duvoux ◽

Paolo Angelo Cortesi ◽

Rita Facchetti ◽

Speranta Iacob ◽

...

Keyword(s):

Liver Disease ◽

Respiratory Failure ◽

Meld Score ◽

Decompensated Cirrhosis ◽

Cox Regression Analysis ◽

Post Transplant ◽

End Stage Liver Disease ◽

Significant Difference ◽

End Stage ◽

The Impact

ObjectiveExplore the impact of COVID-19 on patients on the waiting list for liver transplantation (LT) and on their post-LT course.DesignData from consecutive adult LT candidates with COVID-19 were collected across Europe in a dedicated registry and were analysed.ResultsFrom 21 February to 20 November 2020, 136 adult cases with laboratory-confirmed SARS-CoV-2 infection from 33 centres in 11 European countries were collected, with 113 having COVID-19. Thirty-seven (37/113, 32.7%) patients died after a median of 18 (10–30) days, with respiratory failure being the major cause (33/37, 89.2%). The 60-day mortality risk did not significantly change between first (35.3%, 95% CI 23.9% to 50.0%) and second (26.0%, 95% CI 16.2% to 40.2%) waves. Multivariable Cox regression analysis showed Laboratory Model for End-stage Liver Disease (Lab-MELD) score of ≥15 (Model for End-stage Liver Disease (MELD) score 15–19, HR 5.46, 95% CI 1.81 to 16.50; MELD score≥20, HR 5.24, 95% CI 1.77 to 15.55) and dyspnoea on presentation (HR 3.89, 95% CI 2.02 to 7.51) being the two negative independent factors for mortality. Twenty-six patients underwent an LT after a median time of 78.5 (IQR 44–102) days, and 25 (96%) were alive after a median follow-up of 118 days (IQR 31–170).ConclusionsIncreased mortality in LT candidates with COVID-19 (32.7%), reaching 45% in those with decompensated cirrhosis (DC) and Lab-MELD score of ≥15, was observed, with no significant difference between first and second waves of the pandemic. Respiratory failure was the major cause of death. The dismal prognosis of patients with DC supports the adoption of strict preventative measures and the urgent testing of vaccination efficacy in this population. Prior SARS-CoV-2 symptomatic infection did not affect early post-transplant survival (96%).

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Availability of Services and Caregiver Burden: Supporting Individuals With Neurogenetic Conditions During the COVID-19 Pandemic

Journal of Child Neurology ◽

10.1177/08830738211001209 ◽

2021 ◽

pp. 088307382110012

Author(s):

Michelle Kowanda ◽

Lindsey Cartner ◽

Catherine Kentros ◽

Alexa R. Geltzeiler ◽

Kaitlyn E. Singer ◽

...

Keyword(s):

Caregiver Burden ◽

Educational Programs ◽

Medical Systems ◽

Medical Needs ◽

Neurodevelopmental Disabilities ◽

Delivery Of Services ◽

The Impact ◽

The Relationship

Because of the COVID-19 pandemic, in-person services for individuals with neurodevelopmental disabilities were disrupted globally, resulting in a transition to remote delivery of services and therapies. For individuals with neurogenetic conditions, reliance on nonclinical caregivers to facilitate all therapies and care was unprecedented. The study aimed to (1) describe caregivers’ reported impact on their dependent’s services, therapies, medical needs, and impact on themselves as a result of the COVID-19 pandemic and (2) assess the relationship between the extent of disruption of services and the degree of self-reported caregiver burden. Two online questionnaires were completed by caregivers participating in Simons Searchlight in April and May 2020. Surveys were completed by caregivers of children or dependent adults with neurodevelopmental genetic conditions in Simons Searchlight. Caregivers reported that the impact of the COVID-19 pandemic moderately or severely disrupted services, therapies, or medical supports. The majority of caregivers were responsible for providing some aspect of therapy. Caregivers reported “feeling stressed but able to deal with problems as they arise,” and reported lower anxiety at follow-up. Caregivers reported that telehealth services were not meeting the needs of those with complex medical needs. Future surveys will assess if and how medical systems, educational programs, therapists, and caregivers adapt to the challenges arising during the COVID-19 pandemic.

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A usability and feasibility study of a computerized version of the Bath Adolescent Pain Questionnaire: the BAPQ-C

BMC Pediatrics ◽

10.1186/s12887-019-1899-3 ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Abbie Jordan ◽

Fiona M. Begen ◽

Lisa Austin ◽

Rhiannon T. Edwards ◽

Hannah Connell

Keyword(s):

Chronic Pain ◽

Electronic Version ◽

Self Report ◽

Thinking Aloud ◽

Pain Questionnaire ◽

Paper Version ◽

Home Based ◽

Functional Aspects ◽

Ideal Tool ◽

The Impact

Abstract Background Pain is a common experience in adolescence, with up to 44% of adolescents reporting chronic pain. For a significant minority, severe pain becomes an ongoing disabling problem. Treatment of adolescent chronic pain aims to reduce the impact of pain on adolescents’ lives. Efficient, accurate assessment of the impact of pain is essential to treatment. The ‘Bath Adolescent Pain Questionnaire’ (BAPQ) is a psychometrically robust multidimensional self-report measure of adolescent functioning. Whilst widely used, the paper-based format of the BAPQ can present completion difficulties for adolescents experiencing chronic pain. To increase the accessibility and clinical utility of the BAPQ, an electronic version of the measure is needed. This study assesses the usability and feasibility of a computerized version of this measure (BAPQ-C) in an adolescent chronic pain population. Methods Fourteen adolescents (13 females; 13–16 years) were recruited from a hospital-based residential pain management programme. Participants completed a qualitative ‘thinking aloud task’ whilst completing the BAPQ-C. and, an acceptability questionnaire regarding the BAPQ-C. Data were analysed using thematic analysis, a widely used qualitative method of data analysis . Results Two themes labelled ‘engagement and technological appeal’ and ‘accessibility and independence’ were generated. Themes revealed numerous factors contributing to participants’ preference for the BAPQ-C compared with the paper version of the BAPQ. Participants reported that the BAPQ-C was ‘quicker’ and ‘easier’ to complete than the BAPQ. Functional aspects of the BAPQ-C which included use of a touch screen rather than a pen and paper, font colours/styles, the zoom function and the spellchecker, provided participants with improved access. This subsequently increased participants’ independence and confidence when completing the measure. Conclusion The BAPQ-C is a feasible multidimensional tool for the assessment of functioning in adolescents who experience chronic pain. It was well-received by participants who were able to complete the measure more quickly, independently and confidently than the paper-based BAPQ. Increased speed, ease and accuracy of completion make the BAPQ-C an ideal tool for use in busy clinical and research settings. Findings highlight the potential benefits of adopting the BAPQ-C when assessing the impact of chronic pain on adolescents in clinic and home-based settings.

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THE IMPACT OF AN EPILEPSY-CARE BUNDLE ON THE MANAGEMENT OF ACUTE SEIZURES IN A LARGE LONDON-BASED DISTRICT GENERAL HOSPITAL

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2015-312379.2 ◽

2015 ◽

Vol 86 (11) ◽

pp. e4.107-e4

Author(s):

Aravindhan Baheerathan ◽

Kohilan Gananandan ◽

Orlando Swayne

Keyword(s):

District General Hospital ◽

Business Case ◽

Medical Emergency ◽

Initial Assessment ◽

Care Bundle ◽

Staff Turnover ◽

Acute Seizures ◽

Neuro Imaging ◽

The Impact

IntroductionSeizures account for 2–3% of presentations to the Accident & Emergency department. The National Audit of Seizure management in Hospitals (NASH) has demonstrated significant variances with regards to initial assessment and subsequent management. Standardised management protocols are crucial in optimising the care of this commonly encountered medical emergency.MethodsThe care of 30 patients admitted with seizures over a 1–month period was retrospectively reviewed. Following this a trust-wide seizure bundle was implemented and another 30 patients were reviewed. Data collection specifically assessed: ▸ Demographics of patients admitted, ▸ Immediate assessment & initial investigations, ▸ Consequent neuro-imaging & specialist investigations, ▸ Referral pathway.ResultsThe results showed poor uptake of the bundle and consequently management was broadly unchanged. The most significant results were:▸ 24% of cases did not have a senior review▸ 70% of cases were not discussed with neurology▸ 36% of cases did not have any follow up arrangedConclusionThe implementation of a seizure bundle can be challenging in the context of a unit that has a rapid staff turnover and is heavily staffed by locum physicians. Repeated staff education is required. This evidence is being used in a business case to employ an epilepsy nurse at Northwick Park. (Aravindhan Baheerathan and Kohilan Gananandan will both be presenting authors and contributed equally to this abstract).

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Homeless youth in London: II. Accommodation, employment and health outcomes at 1 year

Psychological Medicine ◽

10.1017/s0033291799001488 ◽

2000 ◽

Vol 30 (1) ◽

pp. 187-194 ◽

Cited By ~ 34

Author(s):

T. K. J. CRAIG ◽

S. HODSON

Keyword(s):

Substance Use ◽

Young People ◽

Psychiatric Disorder ◽

Health Outcomes ◽

Homeless Youth ◽

Homeless People ◽

Antisocial Behaviour ◽

Medical Needs ◽

The Impact

Background. While there is considerable evidence of a high prevalence of psychiatric disorder among homeless youth, much less is known about its long-term course or the impact it may have on accommodation outcomes.Method. A random sample of 161 homeless people 16–21 years of age were recruited from consecutive attendees at two of London's largest facilities for homeless young people. These young people were traced and re-interviewed a year later to examine accommodation, occupation and health outcomes.Results. A total of 107 (67%) people were successfully re-interviewed. Psychiatric disorder was identified in 55% at follow up. Two thirds of those with a psychiatric disorder at index interview remained symptomatic at follow-up. Persistence of psychiatric disorder was associated with adverse childhood experiences and rough sleeping. Satisfactory accommodation outcomes were achieved by 45 subjects (42%). Better accommodation outcomes were associated with three variables measured at the index assessment: ethnic minority status; educational achievement; and, the presence of accommodation plans negotiated through a resettlement agency. While psychiatric disorder at index interview was not associated with accommodation outcome, persistent substance use in the follow-up year was associated with poor accommodation outcome. Over half of the young people had been involved in petty crime and just under a third had been convicted for more serious criminal activity. Offending and antisocial behaviour in the follow-up year were related to a history of conduct disorder, persistent substance abuse and poor accommodation outcomes.Conclusions. Young homeless people are characterized by multiple social and medical needs. Successful resettlement of this population may depend upon integrated services that address problems of persisting substance use and mental illness as well as the immediate housing need.

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Impact Of Age On Toxicity Associated With Chemotherapy For Acute Lymphoblastic Leukaemia (ALL): Results From The UK Prospective Study UKALL2003

Blood ◽

10.1182/blood.v122.21.840.840 ◽

2013 ◽

Vol 122 (21) ◽

pp. 840-840

Author(s):

Rachael E. Hough ◽

Clare Rowntree ◽

Rachel Wade ◽

Nicholas Goulden ◽

Chris Mitchell ◽

...

Keyword(s):

Conflicts Of Interest ◽

Residual Disease ◽

Age Groups ◽

Serious Adverse Events ◽

Number Of Patients ◽

Teenagers And Young Adults ◽

The Uk ◽

Cure Rates ◽

The Impact

Abstract Despite the substantial improvements made in the outcomes of paediatric ALL, with ‘cure' rates now in excess of 90%, survival in teenage and young adult (TYA) patients has remained inferior. The reasons for this are likely multifactorial, including tumour biology, toxicity, compliance, access to clinical trials and protocol (adult or paediatric) used. We report the toxicity profiles observed in children, teenagers and young adults treated on the UK intensive, minimal residual disease (MRD) directed ALL protocol, UKALL2003. Of a total of 3126 patients treated, 1520 patients were under 5 years old, 767 were aged 5-9 years, 610 aged 10-15 years and 229 aged 16-24 years, with a median overall follow-up of 4 year and 10 months. The risk of serious adverse events (SAEs) was higher in patients older than 10 years (56% in 10-15 year olds, 53% in 16-24 year olds) compared to those aged 9 or younger (30% in under 5 years and 31% in 5-9 years)(p<0.0001), with no difference in the those aged 16-24 compared to younger teenagers (p=0.5). The incidence (per number of patients in each group) and distribution of toxicities according to age group is summarised in the table.Table 1Age in years<55-910-1516-24AllTotal number of patients1520767610229 NB: 56 pts≥20 years3126Infection n (%)328 (21.6%)130 (17.0%)145 (23.8%)72 (31.4%)675 (21.6%)Asaparaginase n (%)57 (3.8%)57 (7.4%)64 (10.5%)31 (13.5%)209 (6.7%)Methotrexate n (%)100 (6.6%)74 (9.6%)123 (20.2%)33 (14.4%)330 (10.6%)Steroid n (%)54 (3.6%)37 (4.8%)141 (23.1%)52 (22.7%)284 (9.0%)Vincristine n (%)34 (2.2%)11 (1.4%)22 (3.6%)7 (3.0%)74 (2.4%)Other SAEs94 (6.2%)42 (5.5%)90 (14.8%)25 (10.9%)251 (8.0%) The incidence of certain toxicities including viral infection (5.3%), asparaginase hypersensitivity (1.9%) and vincristine neurotoxicity (2.1%) appeared equivalent across all age groups. Avacular necrosis was seen predominantly in adolescents (83% of 147 events in 10-19 year olds) and was rare in those younger than 10 years (n=18) or older than 20 years (n=7). Asparaginase thrombotic events increased in frequency with increasing age (1.5% in under 5 years, 3.3% in 5-9 years, 4.4% in 10-15 years and 8.3% in 16-24 year olds)(p<0.0001). All other toxicities were more frequently observed in over 10 year olds compared to patients aged 9 or younger, with no difference between 16-24 year olds and 10-15 year olds. The impact of age on SAEs associated with intensive ALL chemotherapy varies according to specific toxicities. In general, toxicity is higher in those over 10 years compared to younger patients, with no excess toxicity in those aged 16-24 compared to 10-15 years. However, specific toxicities may increase with increasing age (thrombosis), be restricted to adolescence (AVN) or be unrelated to age (vincristine neurotoxicity, asparaginase hypersensitivity). Disclosures: No relevant conflicts of interest to declare.

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Are we allowed to visit now? Concerns and issues surrounding vaccination and infection risks in UK care homes during COVID-19

10.1101/2021.05.20.21257545 ◽

2021 ◽

Author(s):

Clarissa Marie Giebel ◽

Kerry Hanna ◽

Jacqueline Cannon ◽

Paul Marlow ◽

Hilary Tetlow ◽

...

Keyword(s):

Scientific Evidence ◽

Care Home ◽

Home Visitation ◽

Control Measures ◽

Care Homes ◽

Family Carers ◽

Care Home Staff ◽

The Uk ◽

The Impact

Background: Vaccination uptake in the UK and increased care home testing are likely affecting care home visitation. With scant scientific evidence to date, the aim of this longitudinal qualitative study was to explore the impact of both (vaccination and testing) on the conduct and experiences of care home visits. Methods: Family carers of care home residents with dementia and care home staff from across the UK took part in baseline (October/November 2020) and follow-up interviews (March 2021). Public advisers were involved in all elements of the research. Data were analysed using thematic analysis. Results: Across 62 baseline and follow-up interviews with family carers (n=26; 11) and care home staff (n=16; 9), five core themes were developed: Delayed and inconsistent offers of face-to-face visits; Procedures and facilitation of visits; Frustration and anger among family carers; Variable uptake of the COVID-19 vaccine; Misinformation, education, and free choice. The variable uptake in staff, compared to family carers, was a key factor seemingly influencing visitation, with a lack of clear guidance leading care homes to implement infection control measures and visitation rights differently. Conclusions: We make five recommendations in this paper to enable improved care home visitation in the ongoing, and in future, pandemics. Visits need to be enabled and any changes to visiting rights must be used as a last resort, reviewed regularly in consultation with residents and carers and restored as soon as possible as a top priority, whilst more education needs to be provided surrounding vaccination for care home staff.

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Use of Telemedicine for Chronic Liver Disease at a Single Care Center During the COVID-19 Pandemic: Prospective Observational Study (Preprint)

10.2196/preprints.20874 ◽

2020 ◽

Cited By ~ 1

Author(s):

Maria Guarino ◽

Valentina Cossiga ◽

Andrea Fiorentino ◽

Giuseppina Pontillo ◽

Filomena Morisco

Keyword(s):

Health Care ◽

Liver Disease ◽

Observational Study ◽

Chronic Liver Disease ◽

Prospective Observational Study ◽

Care Delivery ◽

Care Center ◽

Social Distancing ◽

The Impact

BACKGROUND The COVID-19 outbreak has overwhelmed and altered health care systems worldwide, with a substantial impact on patients with chronic diseases. The response strategy has involved implementing measures like social distancing, and care delivery modalities like telemedicine have been promoted to reduce the risk of transmission. OBJECTIVE The aim of this study was to analyze the benefits of using telemedicine services for patients with chronic liver disease (CLD) at a tertiary care center in Italy during the COVID-19–mandated lockdown. METHODS From March 9 to May 3, 2020, a prospective observational study was conducted in the Liver Unit of the University Hospital of Naples Federico II to evaluate the impact of (1) a fully implemented telemedicine program, partially restructured in response to COVID-19 to include video consultations; (2) extended hours of operation for helpline services; and (3) smart-working from home to facilitate follow-up visits for patients with CLD while adhering to social distancing regulations. RESULTS During the lockdown in Italy, almost 400 visits were conducted using telemedicine; only patients requiring urgent care were admitted to a non–COVID-19 ward of our hospital. Telemedicine services were implemented not only for follow-up visits but also to screen patients prior to hospital admission and to provide urgent evaluations during complications. Of the nearly 1700 patients with CLD who attended a follow-up visit at our Liver Unit, none contracted COVID-19, and there was no need to alter treatment schedules. CONCLUSIONS Telemedicine was a useful tool for following up patients with CLD and for reducing the impact of the COVID-19 pandemic. This system of health care delivery was appreciated by patients since it gave them the opportunity to be in contact with physicians while respecting social distancing rules.

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Assessing the Prognostic Performance of the Child-Pugh, Model for End-Stage Liver Disease, and Albumin-Bilirubin Scores in Patients with Decompensated Cirrhosis: A Large Asian Cohort from Gastroenterology Department

Disease Markers ◽

10.1155/2020/5193028 ◽

2020 ◽

Vol 2020 ◽

pp. 1-9 ◽

Cited By ~ 2

Author(s):

Si-Zhe Wan ◽

Yuan Nie ◽

Yue Zhang ◽

Cong Liu ◽

Xuan Zhu

Keyword(s):

Liver Disease ◽

Roc Curve ◽

Meld Score ◽

The Other ◽

Decompensated Cirrhosis ◽

Short Term ◽

End Stage Liver Disease ◽

End Stage

Background and Aim. Various methods, including the Child-Pugh score, the model for end-stage liver disease (MELD) score, the MELD combined with serum sodium concentration (MELD-Na) score, the integrated MELD (iMELD) score, and the albumin-bilirubin (ALBI) score, have been widely used for predicting the survival of decompensated cirrhosis (DeCi) patients. In this study, we defined and compared the prognostic value of these scores to predict mortality in DeCi patients. Methods. We performed a single-center, observational retrospective study and analyzed 456 DeCi patients who were hospitalized in the gastroenterology department. The biochemical examination results and demographic characteristics of the patients were obtained, and five scores were calculated upon admission after 24 hours. All patients were observed until death, loss to follow-up, or specific follow-up times (28 days, 90 days, and 6 months). A receiver operating characteristic (ROC) curve was used to evaluate the ability of these methods to predict mortality in DeCi patients. Results. At 28 days, 90 days, and 6 months, the cumulative number of deaths was 50 (11.0%), 76 (16.6%), and 91 (19.9%), respectively. The scores were significantly higher in nonsurviving patients than in surviving patients. All scores yielded viable values in predicting 28-day, 90-day, and 6-month prognoses for DeCi patients. The areas under the ROC curve (AUROCs) of the ALBI score were higher than those of the other scores, which were only over 0.700 at 28 days. The AUROC of the MELD score was higher than that of the other scores, including the MELD-Na and iMELD scores, at 90 days and 6 months. Conclusion. All five methods (Child-Pugh score, MELD score, MELD-Na score, iMELD score, and ALBI score) provided a reliable prediction of mortality for both the short-term and long-term prognosis of patients with DeCi. The ALBI score may be particularly useful for assessing short-term outcomes, whereas the MELD score may be particularly useful for assessing long-term outcomes.

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