NHS GRAMPIAN REVIEW OF NEW GUIDANCE FOR VARICEAL SCREENING

Introduction Covid-19 pandemic caused significant disruption to elective endoscopy services nationally. This paved way to endoscopy minimised management pathways for patients with liver cirrhosis. Standard pathway pre-COVID19 was as set out in Baveno VI consensus guidelines and involved variceal screening endoscopy for all patients with clinically significant portal hypertension. We adopted the new pathway as suggested by the national clinical forum, endorsed by the Scottish Government, which proposes the use of Carvedilol in patients with clinically significant portal hypertension and endoscopy reserved for patients who are intolerant of carvedilol or have contraindications to beta-blocker use. The rationale behind new guidance is the improvement in survival with Carvedilol and its efficacy in reducing hepatic venous pressure gradient and preventing decompensation. The recent Baveno VII consensus also suggests patients established on Carvedilol therapy do not need endoscopy as it is unlikely to change clinical management. We aim to assess the impact of applying the new guidance on the variceal screening/surveillance endoscopy waiting list. Methods 243 patients were identified on our variceal endoscopy waiting list who were due an endoscopy between 2019 and 2024. Patients on variceal banding programme have been excluded from this analysis. Data collected included their Childs Pugh score, fibroscan score, medications, platelet count and previous endoscopy results if applicable. Patients were then categorised into three groups. 1. Clinical monitoring of blood tests and fibroscan yearly without endoscopy 2. Carvedilol therapy indicated 3. To continue with endoscopic screening. Results 26/243 (10.6%) patients were removed from the waiting list with plan for yearly monitoring. 10/243 (4%) patients were to continue with endoscopic screening due to Carvedilol intolerance. 207 patients met the criteria to commence Carvedilol without the need for endoscopy. Therefore, 207/233 (88%) patients could be removed from the waiting list by applying the new guidance. This would free up approximately 29 endoscopy lists which can be utilised to address other areas within gastroenterology and hepatology service with longer waiting times. Conclusions The impact on variceal endoscopy waiting times by adopting the new guidance is significant. It provides opportunity to utilise the resources more effectively. From patient's perspective, endoscopy is an invasive procedure and anxiety provoking to some patients resulting in failure to attend endoscopy appointments. As the requirement for endoscopy is considerably low, the new guidance may be more acceptable to patients who prefer to avoid endoscopy. Patient compliance and tolerance to Carvedilol will be recorded prospectively to assess the overall impact on the service.

NURSE LED CLOSE MONITORING CLINIC FOR PATIENTS WITH DECOMPENSATED LIVER DISEASE OR DERANGED LIVER FUNCTION

Introduction Emergency admission to hospital with decompensated liver disease (DLD) is a common medical presentation and carries a high mortality (10-20%)(1). Due to the nature of the disease and the associated complexities, the Close Monitoring Clinic (CMC) was set up to facilitate appropriate review post discharge with the aim of allowing early discharge, reducing re-admission rates and to provide education and support to patients. Aims and objectives To effectively manage and support patients with features of decompensated liver disease following discharge from the Gastroenterology Ward. The clinic also has capacity to review patients with other liver conditions who require close monitoring. Reduce the workload of medical staff and ensure patients are seen within 1-2 weeks post discharge in an attempt to reduce the readmission rate. Methods Clinic Commenced in 02/07/2019, half hour appointments were allocated to each patient. Nurses have completed clinical examination skills training and are independent prescribers. An MDT was introduced for discussion of patients with medical, pharmacy, nursing staff the following day when blood results available. It is planned the Palliative care team will join this MDT. It was initially thought that 4 clinic slots per week would be sufficient to accommodate all patients, however we had to increase this according to demand. Results To date (14/02/2022) there have been 500 appointments offered, only 42 appointments were not attended, giving an attendance rate of 92%. There have been 174 individuals offered appointments for the clinic, with a mean number of appointments per patient being 2 (range 1-28). The demographics show that 102 (58%) patients are male, the average age of those offered appointments was 58years old (range22-89). The aetiology of the need for an appointment can be seen in Chart 4. The time from discharge and appointment request (1-2 weeks) to time of actual appointment offered in a 20% sample is 85% of patients offered an appointment within the requested time frame. Conclusion The close monitoring clinic is an invaluable service, reducing the number of appointments required by medical staff. During the COVID-19 pandemic, we continued to see these patients face to face and if required arrange planned admissions mainly for ascitic drainage, reducing the workload on emergency care staff and GPs. These patients whilst in hospital are in a critical condition and often have had a near death experience have found the psychological support and the availability of telephone advice between appointments invaluable. The 'did not attend' rate is extremely low at 8%, which is incredible given the high number of patients with alcohol related aetiology.

Service evaluation of a patient centred pathway to support self management and weight loss for patients with non-alcoholic fatty liver disease

With increasing rates of obesity, non-alcoholic fatty liver disease (NAFLD) is now the most common cause of abnormal liver function tests (LFTs) in the UK.1 Lifestyle change is the mainstay of clinical management for NAFLD.2Patients achieving ≥ 5-10% weight reduction show regression in fibrosis score and improvements in histological aspects of NAFLD.3 However, there is limited evidence of what works to support weight loss/improve self management in clinical settings. Evidence highlights just providing patients with NAFLD with information and advice to change behaviour is an insufficient intervention. Readiness to change weight-related behaviours is often low and not associated with severity of liver disease. The Lead Clinician and Hepatology Nurse Specialist led on development of a new NAFLD pathway. They established a multidisciplinary clinic with input General Practitioners, dietitians and psychologists. Eligible patients (Fib 4>1.45) were offered input from a Liver Nurse, Health Psychologist, dietitian and Consultant. Over 6 months patients received a low intensity psychology intervention. Each participant was seen for an assessment (and 8 weekly follow-ups via email, telephone or video call). Psychologist reviewed patients at three and six months. 101 patients, (53% Males and 47% Females) agreed to participate in the health psychology intervention. Average BMI of patients assessed was 40.1 (113.5kg). Baseline daily step count was 1635. Majority of patients presented with two or more Long Term Conditions alongside NAFLD. Most common being Type 2 Diabetes (44%) and anxiety/depression (27%). Average Fib 4 score was 1.4, KPa 14.4. HbA1c 58.8, Cholesterol 5.0, ALT 81.4, AST 58.4. 91% of patients were followed up (9% drop out). Average weight loss 5.5kg (range 0.5kg- 23kg). 82% increased daily step count (1635 to 5958). Anxiety scores (HADs) decreased from (7.4 to 6) and Depression scores reduced 6.3 to 3.3 Due to Covid 19 restrictions we don't have repeat measures on medical markers. However self reported outcomes at 6 months are encouraging. A learning point when we are able to fully resume normal service delivery is to try and increase the number of patients benefitting from this service. We see scope to access patients earlier in primary care thus reducing waiting times and freeing up secondary care medical staff for more complex cases. Overall, it is considered that this new pathway and multidisciplinary clinic has been very worthwhile. There were noticeable improvements identified through the use of appropriate assessment tools and from positive qualitative patient/ clinician feedback.