A new nurse-led ‘one-stop’ clinic for cirrhosis patients reduces unplanned liver-related readmissions and improves survival BMC Gastroenterology

put one’s oar in

After index hospital presentation to patients with cirrhosis at Blacktown or Mount Druitt Hospital, patients were followed continuously in a nurse-led clinic (intervention cohort) or received standard hepatologist-led care as an inpatient or outpatient as needed (control group) . Interventions include goal-directed, protocolized cirrhosis care for hepatic encephalopathy, ascites, gastroesophageal varices, alcohol and drug abuse, malnutrition, psychosocial and post-discharge care. Given the nature of the intervention, blinding participants and staff was not feasible. The nurse-led intervention was a one-stop visit to the nurse-led cirrhosis clinic at Blacktown Hospital, or patients were visited by a participating study nurse during their stay. The intervention lasted 30 minutes and was delivered to a nurse-led clinic during hospitalization and within 7 days after discharge. Figure 1 provides an overview of the nurse-assisted intervention. The nurses participating in the study were proficient in the field of liver disease, had 9 years of experience in inpatient or outpatient care of liver diseases, and had a comprehensive understanding of cirrhosis. Demographics, vital signs, and extensive laboratory data were recorded for all patients in the intervention cohort. Nurses play a key role in initiating and maintaining healthy lifestyle behaviors and guiding patients and their families in care planning and goal setting. Inclusion of nurses in the interprofessional team facilitates early involvement of allied health professionals such as dietitians (sodium and/or water restriction, specific dietary measures for hepatic encephalopathy), physiotherapists, psychologists and social workers, and further facilitated the introduction of other health-informed professionals and appropriate referrals (Alcohol Review Team and/or Obesity Clinic referral). In addition, nurses work with patients and caregivers to teach them how to recognize early symptoms and contact health care professionals. Patients in the intervention cohort were comprehensively assessed for potential complications or disease exacerbations, particularly after or at discharge, through activation of the discharge care package. Comprehensive assessment includes observation for signs of decompensation (e.g., effusion, gastroesophageal bleeding, altered mental status, jaundice), risk prevention, and comorbidities (frailty, malnutrition, sarcopenia, and fall risk assessment, COVID-19, pneumococcal pneumonia , influenza and tetanus vaccinations, hepatitis A and B serology testing, gastroesophageal variceal screening, and other symptoms that may cause additional stress for the patient. In addition to specific signs of disease, patients are also monitored for other symptoms, Examples include pain, dyspnea, difficulty sleeping, and/or anxiety. Further monitor treatment compliance and potential side effects (review doses of diuretics used to control ascites and/or lactulose used to treat and/or prevent HE, Non-selective beta-blockers, norfloxacin, or trimethoprim-sulfamethoxazole for the prevention of spontaneous bacterial peritonitis (gastrointestinal bleeding). In addition, nurses facilitated real-life experiments room and necessary radiological examinations, liver elastography was performed to capture disease progression. Due to the increased risk of developing hepatocellular carcinoma, liver ultrasonography was performed in all patients. In addition, psychosocial factors were explored to determine the relationship with assistance Additional needs related to increased dependence, fear of death, etc. Patients in the inpatient intervention cohort are managed according to recent guidelines and recommendations. Patients in the intervention cohort have follow-up phone calls or telemedicine appointments during the first week or as needed during the study period or visit the clinic to maintain contact with post-hospital care. Primary care providers are informed of real-life laboratory and procedural investigations, treatment plans, or any changes.

Standard care (control group) included inpatient or outpatient visits or physician follow-up calls, gastroscopy, ascites drainage, and registered nurse telephone consultation by a nurse not participating in the study. In this cohort, after discharge, responsibility for management according to existing guidelines and protocols is delegated to the attending physician, with on-demand support from specialists.

study population

We included 89 patients with cirrhosis aged >18 years diagnosed using standard clinical criteria, consistent radiographic evidence of cirrhosis, or transient wave elastography (>20 kPa) and/or liver biopsy. If a patient with chronic liver disease has endoscopic or radiographic evidence of varicose veins or a platelet count <150,000/mm3³ and an aspartate aminotransferase/alanine aminotransferase ratio > 1 were also included. For this analysis, we included 41 control patients and 48 intervention cohort patients. The sample size was determined using the Cochran formula for sample size calculation. Based on estimates of admission rates for cirrhosis over three months and readmission rates of up to 50%, with a Z-score of 95% confidence level (1.96) and a precision of 0.05, the minimum sample size was calculated to be 80 years.

Patients were excluded if they: a) consumed alcohol regularly, which would be expected to impede proper compliance with the study b) had a history of significant non-liver disease with compromised short-term prognosis (heart failure NYHA class III/IV, COPD GOLD class C or The above, dementia, stroke sequelae, severe mental illness and renal failure requiring dialysis) c) Patients with hepatic encephalopathy grade 2-4, because sufficient time is needed on admission to rule out other conditions similar to hepatic encephalopathy and correct the sudden event. d) Patients currently suffering from non-hepatic malignancies, including solid tumors and hematological diseases e) Patients with hepatocellular carcinoma, patients with early-stage HCC (BCLC-0 or BCLC-A) or patients with a past history of HCC who have not relapsed within 2 years Exceptions are f) patients receiving antiviral therapy for HCV or those who have been treated within the past 12 months, for whom a positive effect on clinical decompensation may be seen with long-term antiviral therapy g) patients receiving antiviral therapy for HBV for less than 12 months Patients aged 12 months to 12 months should avoid interference with the effect of treatment of the cause. h) Patients receiving corticosteroids for less than 6 months for autoimmune hepatitis i) TIPS implanted within 6 months before inclusion in the study, as TIPS implantation can alter the natural history of cirrhosis (increase survival and reduce loss of life) k) Acute episode-chronic liver failure j) Planned admission (Figure 2. Flow chart of study participants).

The study evaluated a total of 260 patients with cirrhosis between December 2021 and February 2023. Only 198 patients met inclusion criteria. After index presentation to Blacktown or Mount Druitt Hospital (BMDH), patients (matched by age, sex and MELD-NA score) were followed consecutively by a CCoLD clinical nurse consultant (intervention cohort, n= 48) or received standard care (control group, n= 41). Patients in both groups were followed up for 90 days after discharge.

Ethical approval and informed consent

Ethical approval was obtained from the Western Sydney Local Health District Human Research Ethics Committee (Ethical Approval 2021/ETH00149). All studies were conducted in accordance with the Declaration of Helsinki. All participants signed an informed consent form before the start of the project.

result

Primary outcomes included time to first readmission, readmission rate, and mortality (30 and 90 days). Liver-related unplanned readmission was defined as any unplanned readmission requiring hospitalization for ascites, pleural effusion, or renal failure associated with liver disease, hepatic encephalopathy, and esophageal or gastric variceal bleeding, or any combination thereof. Our analysis also includes an economic evaluation of the CCoLD project, including the cost-effectiveness and financial sustainability of CCoLD as secondary outcomes. Healthcare resource use, particularly in relation to cirrhosis, is informed by clinical audit and includes health professional consultations (primary and secondary care), admissions (day care, hospitalization, emergency department visits), investigations and treatments , including over-the-counter medications. Informal home care, patient time spent using health services, and transportation costs were not included.

Statistical Analysis

Clinical data including demographics, primary diagnosis on admission, and liver disease stage were analyzed. Variables are expressed as mean with standard deviation or median with interquartile range (IQR). Student’s t test was used to compare continuous variables, and chi-square test or Fisher’s exact test was used to compare categorical variables.all ask– the value is two-tailed, and ask– Values ​​less than 0.05 are considered statistically significant. IBM SPSS® Statistics (version 28.0.1.1; IBM Corp., Armonk, NY, USA) was used for statistical analyses. The potential confounding effect of comorbidities was avoided by matching patients to a diagnosis-based chronic disease score (i.e., the Charlson index), which was adjusted for patients with chronic liver disease.