Outcomes of Patients Admitted to Critical Care Services with Decompensated Alcohol Liver Disease

Gautham Appanna, Mark Andrews, Leanne Griffin, Rob Bevan, Timothy Asibey-Berko, Rhys Howell, and Kier Lewis.


Cardiff University, Hywel Dda UHB, ABMU Health Board, Bevan Commission, and Swansea University


Introduction

Alcohol Liver Disease (ALD) is an increasing major cause of preventable death in the United Kingdom, with more patients being referred to Critical Care services with decompensated ALD. In Wales, whilst adult alcohol consumption has fallen slightly since 2008, alcohol consumption in young people remains a concern and is higher than in the rest of the UK. This project aims to record outcomes and through co-production, develop a simple questionnaire to gain more insight from HPs and the public regarding outcomes and compare this to actual data.


Prudent Principle 1

Achieve health and wellbeing with the public, patients and professionals as equal partners through co-production.


Identifying the real outcome data of patients admitted to Critical Care with decompensated alcoholic liver disease should facilitate a more informed discussion between different healthcare professionals, and in collaboration with patients themselves, enabling a more open decision as to whether this should be undertaken.


There is some evidence of poor outcomes in patients with decompensated ALD who present to Critical Care with Multi Organ Failure. When discussing outcomes with various health professionals (HPs) and patients, many do not appear to know the success rates of home discharge after admission to Critical Care.


Prudent Principle 2

Care for those with the greatest health need first, making most effective use of all skills and resources.


Phase 1: Recording outcomes

Between 2013 and 2015, 52 patients (Mean age: 45.2 years) were admitted to Critical Care services at Aneurin Bevan University Health Board with decompensated ALD. 75% of patients had more than one organ failure.


Using validated clinical scoring tools there was a large variation in outcome despite similar ages.


For example:

Child Pugh A cirrhosis → 83% (5/6 patients) survived Child Pugh B cirrhosis → 38% (3/8 patients) survived

Child Pugh C cirrhosis → 13% (5/38 patients) survived


Therefore, by not sending patients to a High Dependency Unit (HDU) who may not survive and may be better and more appropriately served with palliative care, would be a more prudent approach to their care.


Prudent Principle 3

Do only what is needed, no more, no less and do no harm.


Overall, 28% (15/52) patients were alive at 30 days. By identifying which patients with ALD that survive HDU may indicate the characteristics which suggest which patients are most appropriately moved to HDU as opposed to those for whom palliative care may be more appropriate.


Prudent Principle 4

Reduce inappropriate variation using evidence based practices consistently and transparently.


This raises questions regarding patient selection for Critical Care and what treatment approaches (if any) are appropriate. Healthcare Professionals (HCPs) need to have honest discussions with patients and carers, especially those with severe liver disease about mortality and disease course. An approach to this may be earlier involvement of Palliative Care services, to assist with symptom management and Psychological support for both patients and families.


Impacts and future actions

  • Exploration of HCP and public views on outcomes in those admitted to Critical Care with ALD.

  • Compare and contrast outcomes in other centres in Wales.

  • Disseminate findings to patients, HCPs, Service Managers and Policy Makers to inform National Guidelines.

  • Develop interventions e.g. to inform patients and HCPs including:

  1. Benefit: risk ratio calculator for each individual.

  2. Use this evidence to help inform patients to make lifestyle choices.


Part of Cohort Bevan Exemplars 2015-16

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