The Golden 24 Hours: Adherence to an Acute Care Bundle Affects Outcomes for Patients with Decompensated Cirrhosis

Background: Complications related to chronic liver disease (CLD) have led to an increased burden on health services. Despite an improved evidence‐base to support management of complications, suboptimal care persists. Initiatives to improve care for patients with cirrhosis are needed. The decompensated cirrhosis acute care bundle (ACB), developed by the British Society of Gastroenterology (BSG), has been proposed as a roadmap for improved care quality, but impact on patient outcomes has not been demonstrated, nor the relevance to Australian populations. We aimed to assess whether adherence to the BSG‐ACB in the first 24h of hospital admission, was associated with improved outcomes. Methods: Single‐centre, retrospective, observational study of adult patients with decompensated Child Pugh (CP) B/C cirrhosis admitted to a metropolitan tertiary referral centre between the 1/06/2016 and 31/1/2019. Adherence to the BSG‐ACB was assessed for each component, scored and then ranked. Relative adherence was assessed as tertiles from most to least adherent with the BSG‐ACB. Palliative patients were excluded. The primary outcome was mortality (logistic regression). Secondary outcomes were rate of hospital readmission and time to readmission (Kaplan‐Meier). BSG‐ACB adherence was assessed in univariate and then included in a multivariate analysis (MVA) adjusting for other possible predictors of mortality. Results: 159 admissions with decompensated CP B/C cirrhosis were identified and followed‐up for a mean of 328 days (SD 283). 74.2% were male, 43.4% were CP‐B and 56.1% CP‐C. The median MELD score was 18 (IQR 14‐23). Aetiology of CLD was alcohol in 65.4%, non‐alcoholic steatohepatitis 18.9%, viral hepatitis 11.9% and 3.7% other causes. Study mortality was 30.8%. Mortality was highest in patients in the least ACB‐adherent tertile (41.5%), compared to the middle (32.1%) and most adherent tertiles (18.9%) (p = 0.040). On MVA the only independent predictors of patient mortality were ACB‐adherence (p = 0.015), MELD score (p = 0.030) and male gender (p = 0.001) and inclusion of ACB‐adherence attenuated the effect of liver disease severity on mortality. 46% patients were readmitted within the study period. No significant difference in readmission rate was observed; however, patients in the most adherent tertile may have had a longer time until readmission when compared to the least adherent (most adherent tertile 105 days (95% CI 63‐147); middle and least adherent tertiles 81 days (95% CI 56‐106); P =0.227). Conclusion: Adherence to an ACB improved mortality in patients with decompensated liver disease, independent of their liver disease severity. Adoption of an ACB early in admission could help reduce health care burden. Disclosures: Matthew Mickenbecker – Mater Hospital Brisbane: Employment. The following people have nothing to disclose: Andrew Palmer, Alexander Johnston, Hayley Chen, Mazhar M. Haque, Paul J Clark. Disclosure information not available at the time of publication: Timothy O'Sullivan, Nicholas Rigby, Aidan Woodward, Marianne Mortimore, Patricia C Valery.