O2 Implementing a nurse-led early discharge clinic for patients with decompensated chronic liver disease to reduce readmission rates and length of hospital stay

Following a patient’s initial presentation with decompensated liver disease, the condition often progresses rapidly, ultimately resulting in death or liver transplantation (Taper, et al.,2016). In-hospital mortality for this population ranges from 10–20% (Volk et al.,2012), and frequent unplanned readmissions pose significant burden on patients and healthcare services. Most readmissions can be avoided with effective secondary preventative measures; however, patients are frequently readmitted prior to outpatients’ follow-up (Giles, et al.,2023). This project aims to implement a nurse-led Early Discharge Clinic (EDC) for patients with decompensated cirrhosis, intending to optimise patients‘ follow-up, subsequently reducing the waiting list for outpatient clinics, reducing the delay in implementing early interventions, reducing readmission rates and, where possible, the length of hospital stays. This clinic intends also to improve overall patient and families’ experiences, and ultimately reduce costs for the NHS. A first retrospective data analysis was conducted, looking at patients with decompensated cirrhosis admitted to hospital from September to December 2023 (cohort1). Patients’ length of admission, date of first appointment offered, date of first appointment and rate of readmissions between discharge and first outpatient appointment was evaluated. A further quantitative data analysis was conducted after implementing the EDC from February to August 2024 (cohort2). A patient and family feedback form was completed to include qualitative data. Following the implementation of the EDC, patients in cohort 2 experienced significantly shorter hospital stays (8days vs. 15days in cohort 1) and substantially reduced waiting times for outpatient follow-up, with cohort 1 facing delays nearly three times longer. Patients in cohort 2 demonstrated a lower readmission rate. While direct measurement of morbidity and mortality was not feasible in this project, existing evidence supports the association between early intervention and improved clinical outcomes in decompensated liver disease. Notably, 90% of patients and families (cohort2) rated the care received as ‘very good’ or’excellent.’ The implementation of a nurse-led EDC has demonstrated clear value in improving the care of patients with decompensated cirrhosis. While the findings are encouraging, it is important to acknowledge the small sample size. This project remains ongoing and continues to evolve, with the establishment of a direct partnership with dietitians and physiotherapists aiming to further enhance the quality and scope of holistic care provided. Additionally, a notable outcome of the project has been the increased job satisfaction reported by the Specialist Nurses leading the clinic, reinforcing the positive impact of such projects on staff engagement and professional fulfilment. References Adams D. Quality improvement: part 1: introduction and overview. British Journal of Anaesthesia. 2018.18(3):89–94. Aspinal R. Reducing recurrent hospital admissions in patients with decompensated cirrhosis. British Journal of Hospital Medicine. 2018;79(2),64–C32. British Liver Trust (2024). Liver disease in numbers – key facts and statistics. Available: https://britishlivertrust.org.uk/information-and-support/statistics/, accessed 29th September 2024. Burgess N, Radnor Z. Evaluating lean in healthcare. International Journal of Health Care Quality Assurance. 2013;26(3),220–235. Burton R, et al. (2016). Public Health England – the Public Health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies: an evidence review. Available: https://www.gov.uk/government/publications/the-public-health-burden-of-alcohol-evidence-review, accessed 29th September 2024. Care Quality Commission (2024). Adult Inpatient Survey 2023. Available: https://www.cqc.org.uk/publications/surveys/adult-inpatient-survey, accessed 6th October 2024. Critical Appraisal Skills Programme (2024). CASP checklists. Available: https://casp-uk.net/casp-tools-checklists/, accessed 14th July 2024. European Association for the Study of the Liver. EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. Journal of Hepatology. 2018;69:406–460. Fagan K, et al. Burden of decompensated cirrhosis and ascites on hospital services in a tertiary care facility: time for change? Internal Medicine Journal. 2014;44(9):865–872. Ghaoui R, et al. Measurement of the quality of care of patients admitted with decompensated cirrhosis. Liver International. 2014;34(2):204–210. Giles B, et al. Novel, nurse-led early postdischarge clinic is associated with fewer readmissions and lower mortality following hospitalization with decompensated cirrhosis. Frontline Gastroenterology. 2023;15:124–129. Hall S, et al. Exploring the challenges of ethical conduct in quality improvement projects. Canadian Oncology Nursing Journal. 2020;30(1):64–68. Hunt D, et al.Ethical considerations in quality improvement: key questions and a practical guide. BMJ Open Quality. 2021;10(3):1–9. Health Education England (2017). Multi-professional framework for advanced clinical practice in England. Available: https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf,accessed: 29th September 2024). Healthcare Quality Improvement Partnership (2020). A guide to quality improvement tools. Available: https://www.hqip.org.uk/wp-content/uploads/2021/01/Final-Quality-Improvement-QI-Tools-09–12-20.pdf, accessed 6th October 2024. Hershfield G, et al. Preventative hepatology: minimizing symptoms and optimizing care. Liver International. 2008;28(7):204–210. Holloway D, et al. Systematic review of the effectiveness of nurse-led care in reducing glycated haemoglobin in adults with type 1 or 2 diabetes. Internation Journal of Nursing Practice. 2023;29(6), e13135. Horsburgh J, Ippolito K. A skill to be worked at: using social learning theory to explore the process and learning from role models in clinical settings. BMC Medical Education. 2018;18(156),1–8. 19.Im D, et al. Qualitative research in healthcare: data analysis. Journal of Preventive Medicine & Public Health. 2023;56(2),100–110. 20.Kalo E, et al. A novel, nurse-led ‘one-stop- clinic for patients with liver cirrhosis results in fewer liver-related unplanned readmissions and improved survival. BMC Gastroenterology. 2023;23(356),2–9. Kumah A, et al. Cause-and-effect (Fishbone) diagram: a tool for generating and organising quality improvement ideas. Global Journal on Quality and Safety in Healthcare. 2024;7(2),85–87. Langley G, et al. (200) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). California: Jossey-Bass Publishers. ISBN: 978–0-470–19241-2. Martin G, et al. Frameworks for change in healthcare organisations: a formative evaluation of the NHS change model. Health Services Management Research. 2013;26(2–3):65–75. Mansour D, et al. British society of gastroenterology – best practice guidance: outpatient management of cirrhosis – part 2: decompensated cirrhosis. Frontline Gastroenterology. 2023;14:462–473. Moradi T, et al. Delegating care as a double-edged sword for quality of nursing care: a qualitative study. BMC Health Services Research. 2024;24(592):1–12. NHS (2019). The NHS Long term plan. Available: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan-june-2019.pdf, accessed 20th September, 2024. NHS England (2018). The Change Model Guide. Available: https://www.england.nhs.uk/wp-content/uploads/2018/04/change-model-guide-v5.pdf, accessed 6th October 2024. NHS England (2019). Confidentiality Policy. Available: https://www.england.nhs.uk/wp-content/uploads/2019/10/confidentiality-policy-v5.1.pdf, accessed 13th October 2024. NHS England and NHS Improvement (2023). Online library of quality, service improvement and redesign tools – Stakeholder analysis. Available: https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-stakeholder-analysis.pdf, accessed: 5th October 2024. NHS Institute for Innovation and Improvement (2007). Going Lean in the NHS. Available: https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/Going-Lean-in-the-NHS.pdf, accessed 5th October 2024. NHS Institute for Innovation and Improvement (2010). The Handbook of Quality and Service Improvement Tools. Available: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/44/2017/11/the_handbook_of_quality_and_service_improvement_tools_2010–2.pdf, accessed 7th October 2024. NHS Institute for Innovation and Improvement (2017). The how-to guide for measurement of improvement. Available: https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/How-to-Guide-for-Measurement-for-Improvement.pdf, accessed 13th October 2024. NHS Leadership Academy (2024). Healthcare leadership model. Available: https://www.leadershipacademy.nhs.uk/healthcare-leadership-model/, accessed 14th October 2024. Nursing and Midwifery Council (2018). The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf, accessed 13th October 2024. Office for Health Improvement and Disparities (2021). Premature mortality in 2020 in the most deprived vs least deprived deciles for England. Available: https://www.gov.uk/government/statistics/liver-disease-profiles-november-2021-update/liver-disease-profiles-november-2021-update, accessed 20th September 2024. Office for National Statistics (2021). Deaths registered in England and Wales, 2020. Available: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsregisteredinenglandandwalesseriesdrreferencetables on 16th September 2024, accessed 20th September, 2024. Paskoewicz L. The shadowing experience: valuing the link between faculty practice and student learning. Journal of Professional Nursing. 2002;18(4):238–242. Portela M, et al. How to study improvement interventions: a brief overview of possible study types. BMJ Quality and Safety. 2015;24:325–336. Powel A, et al. Effective quality improvement: lean. British Journal of Healthcare Management. 2009;15(6):270–275. Pyo J, et al. Qualitative research in healthcare: necessity and characteristics. Journal of Preventive Medicine & Public Health. 2023;56(1):12–20. Royal College of Nursing (2019). Caring for people with liver disease including liver transplantation: a competence framework for nursing. Available: https://www.rcn.org.uk/Professional-Development/publications/pub-007733, accessed 29th September, 2024. Shah A. Using data for improvement. The British Medical Journal. 2019;364(l189):1–6. Shirey M, et al. Showcasing differences between quality improvement, evidence-based practice, and research. The Journal of Continuing Education in Nursing. 2011;42(2):57–68. Slutsky D. The effective use of graphs. Journal of Wrist Surgery. 2014;3(2):67–68. Smethurst K, et al. Improved outcomes following implementation of a decompensated cirrhosis discharge bundle. Frontline Gastroenterology. 2022;13:409–415. Taper E, et al. A quality improvement initiative reduces 30-day rate of readmission for patients with cirrhosis. Clinical Gastroenterology and Hepatology. 2016;14:753–759. Taper E, et al. Rates of and reasons for hospital readmissions in patients with cirrhosis: a multistate population-based cohort study. Clinical Gastroenterology and Hepatology. 2016;14:1181–8. UK Health Security Agency (2014). Liver disease: a preventable killer of young adults. Available: https://ukhsa.blog.gov.uk/2014/09/29/liver-disease-a-preventable-killer-of-young-adults/, accessed 20th September, 2024. Volt M, et al. Hospital re-admissions among patients with decompensated cirrhosis. American Journal of Gastroenterology. 2012;107:247–252. Watson R. Quantitative research. Nursing Standard. 2015;29(31):44–48. World Health Organization (2008). Commission on Social Determinants of Health. Available: https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1, accessed 29 September 2024. World Health Organization (2016). Combating Hepatitis B and C to reach elimination by 2030. Available: https://www.who.int/publications/i/item/combating-hepatitis-b-and-c-to-reach-elimination-by-2030, accessed 29 September 2024. World Health Organization (2024). European Health Information Gateway. Available: https://gateway.euro.who.int/en/datasets/european-health-for-all-database/, accessed 29 September 2024. Williams R, et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care consumption of alcohol, obesity, and viral hepatitis. The Lancet. 2014;384:1153–1197. Wu X, et al. Effectiveness of nurse-led heard failure clinic: a systematic review. International Journal of Nursing Sciences. 2024;11(3):315–329. Office for Health Improvement and Disparities (2021). Premature mortality in 2020 in the most deprived vs least deprived deciles for England. Available: https://www.gov.uk/government/statistics/liver-disease-profiles-november-2021-update/liver-disease-profiles-november-2021-update, accessed on the 20th September 2024.

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