An audit of the knowledge of the decompensated liver disease bundle and ascitic taps on patients presenting on the medical take

Bellamy, Sabine Ralphs Charlotte Stanley Jack Arnold Oliver Gordon Fiona

BackgroundThe BSG-BASL decompensated cirrhosis care bundle seeks to optimise patient management during the first 24 hours of presentation. The pandemic has impacted on junior doctors’ hepatology training, by reducing access to face-to-face teaching. We sought to redress this by assessing how a remote education programme could affect bundle implementation and awareness, shortly after the UK’ s first COVID-19 wave.MethodsA retrospective snapshot case-note audit was undertaken for 4 weeks (August 2020) at Bristol Royal Infirmary (BRI). Decompensated cirrhosis admissions were identified from coding and bundle usage and compliance with ascitic tap guidance were quantified. An online survey was conducted of BRI junior doctors (medical) to assess knowledge of the bundle and awareness of appropriate ascitic fluid tests. Subsequent quality improvement interventions were developed, with repeat audits in May-June 2021.ResultsThe baseline audit identified appropriate bundle completion in 50% (n=8/16) decompensated cirrhosis patients, none by foundation doctors, with 2 by hepatology consultants. Ascitic tap was attempted in only 50% of patients with detectable ascites (4/8), with recommended tests requested in 2 of 3 successful taps.The online survey (40 participants 42% response) revealed good knowledge of when to use the bundle (85%) and how to access it (90%). For patients with new ascites, 46% of participants identified appropriate tests, however 39/40 also selected unnecessary options. Knowledge was poorer for patients with known ascites;20% selected correct investigations and no participants knew the exact combination to request. Procedural skills varied, 49% of participants had performed an ascitic tap unsupervised, but 33% had never attempted one.After these audits, remote teaching sessions and posters were used to improve prompting of bundle completion;paper copies were distributed to admission areas. Re-audit (May 2020) identified 15 hepatic decompensation admissions, of whom 53% (n=8) had a completed bundle. 9 ascitic taps were attempted in 13 patients with ascites (69%);correct investigations were requested in 5 of 7 taps (71%). At a repeat online survey (32% response rate) 10% (3/30) selected only the necessary investigations for new ascites and 13% (4/30) for recurrent ascites. This indicates that knowledge has not significantly improved.ConclusionThere remained low usage of the BSG-BASL decompensated cirrhosis bundle despite an education campaign. Ascitic tap performance improved but test requesting remained suboptimal. Systematic changes such as IT-system alerts and integrated guidance on key ascites tests within bundle documentation may be more sustainable ways of improving compliance (data will be presented).