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Multi Regional Audit of Blood Component Use in Patients with Cirrhosis

Published March 2014

This project was designed to collect information on patients admitted with a diagnosis of cirrhosis with respect to their use of blood components during the course of their admission. All hospitals registered with the British Society of Gastroenterology (BSG) across the United Kingdom were invited to participate.

The BSG in conjunction with NHS Blood and Transplant (NHSBT) invited all staff on the current BSG membership lists. The project was also supported by the British Association for the Study of Liver Disease (BASL) and Regional Transfusion Committees. Interested parties registered with the BSG. They were then sent supporting documentation plus a link to an online data collection tool. The data collection tool was piloted in 3 sites prior to the main audit and modified using an iterative process. An organisational audit was also carried out to supplement the clinical information.

Executive Summary

  1. This was the first national audit of the use of blood components in patients with cirrhosis.
  2. 85 organisations/hospitals provided data on 1333 consecutive cases of cirrhosis during a 4 week period starting between February – April 2013.
  3. Local hospital audit support was highly variable, which had an impact on the number of completed cases submitted from some hospitals.
  4. The final dataset comprised 1313 cases, with 840/1313 (64%) males, mean age 58 years.
  5. The most common aetiology of cirrhosis was alcohol (70%) followed by non-alcoholic fatty liver disease (12%) and viral hepatitis (11%).
  6. 964/1313 (73%) of admissions were due to decompensated cirrhosis. 275/1313 (21%) cases had a positive septic screen
  7. Case fatality during follow-up was 128/1313 (10%) overall, with decompensated cirrhosis reported as the most frequent cause of death 52/128 (41%).
  8. There were 35/1313 (3%) cases of reported thrombotic events of which 29/1313 (2%) were venous thromboses and 6/1313 (<1%) were arterial thromboses.
  9. 391/1313 (30%) patients were transfused at least one blood component.
  10. For 153/391 (39%) cases the main transfusion indication was prophylaxis (not for bleeding) and for 238/391 (61%) cases the main indication was treatment of bleeding.
  11. For the 238 cases transfused for bleeding, gastro-intestinal bleeding was the most common cause 192/238 (81%). 150/238 (63%) received red cell transfusions alone, which were administered at variable haemoglobin concentrations. In patients with gastrointestinal bleeding who received red blood cells, the pre-transfusion threshold was greater than 80g/L prior to red cell transfusion in 54/220 (25%).
  12. For the 153 cases receiving transfusions for prophylaxis, 94/153 (61%) received transfusions when no procedure was planned. The majority of these were red cell transfusions for the treatment of anaemia 85/94 (90%) but a small number received Fresh Frozen Plasma (FFP) 11/94 (12%) or platelets 5/94 (5%).
  13. For the 59/153 (39%) cases receiving transfusion for prophylaxis prior to interventions, the more common procedures requiring cover by transfusion were paracentesis, surgery and central/femoral line insertion. FFP was the most common single blood component transfused in 34/59 (58%) followed by platelets 25/59 (42%).
  14. 4/72 (6%) hospitals reported having guidelines for patients with liver disease.
  15. In 48/185 (26%) of patients transfused with red cells for gastrointestinal bleeding, the pre-transfusion haemoglobin was greater than 80g/L.
  16. In 103/185 (56%) of patients transfused with red cells for gastrointestinal bleeding, the pre-transfusion haemoglobin was greater than 70g/L.
  17. In 81/101 (80%) of patients transfused with red cells prophylactically, the pre- transfusion haemoglobin was less than 80g/L.
  18. In 13/16 (81%) of patients transfused with FFP prophylactically before a moderate/high- risk procedure, the pre-transfusion INR was greater than 1.5.
  19. In 12/18 (67%) of patients transfused with FFP prophylactically before a low-risk procedure, the pre-transfusion INR was greater than 2.
  20. In 16/25 (64%) of patients transfused with platelets prophylactically before a procedure, the pre-transfusion platelet count was less than 50x109/L

BSG responds to inquiry into alcohol strategy

Tom Smith, BSG Chief Executive

The BSG has submitted formal written evidence to the Health Select Committee's inquiry into the government's alcohol strategy. While the strategy has many strengths it does not present a clear vision for alcohol treatment services and we have highlighted the importance of Alcohol Care Teams in achieving this. We also call for a Minimum Unit Price of not less than 50p. Addressing these issues could present real opportunities for improving lives and mean long-term saving for the NHS. Read more on the BSG's written evidence below:

NICE 'Alcohol Dependence and Harmful Alcohol Use' Quality Standard

Scope of the Quality Standard

This quality standard covers the care of children (aged 10-15 years), young people (aged 16-17 years) and adults (aged 18 years and over) drinking in a harmful way and those with alcohol dependence in all NHS-funded settings. It also includes opportunistic screening and brief interventions for hazardous and harmful drinkers.

Alcohol dependence and harmful alcohol use quality statements

The quality standard refers to harmful drinking and alcohol dependence collectively as 'alcohol misuse'. It requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole care pathway. An integrated, multidisciplinary approach to provision of services is fundamental to the delivery of high-quality care to people who misuse alcohol. A specialist alcohol service is one in which the primary role is the assessment and management of alcohol misuse, including both psychological and physical effects. Some specialist addiction services will have this role for both drug and alcohol misuse.

Survey of Hepatology Service Provision 2010

In 2004 Professor Roger Williams identified 34 centres in England and Wales as offering specialist hepatology services, including 6 liver transplant centres. This March 2010 report is based on a follow up survey six years later. With other sources the survey will help to build a picture of hepatology services in 2010 and how they might be developed.

The National Plan for Liver Services UK 2009

A Time to Act: Improving Liver Health and Outcomes in Liver Disease

liv_graph

Prepared by the:

British Association for the Study of the Liver (BASL)

British Society of Gastroenterology (BSG) (Liver Section)


Key facts

  • Liver disease is the 5th largest cause of death in the U.K. The average age of death from liver disease is 59 years, compared to 82-84 years for heart & lung disease or stroke.
  • Liver disease morbidity and mortality are largely preventable.
  • The UK is one of few developed nations with an upward trend in mortality.
  • Patients are presenting and dying with liver disease at an earlier age, with a 5-fold increase in the development of cirrhosis in 35-55 year olds over the last 10 years
  • The majority of treatable liver disease is undiagnosed and untreated.  Early diagnosis and treatment requires engagement of primary care.
    Attachments:
    Download this file (National Liver Plan 2009.pdf)The national plan for liver services UK 2009[A TIME TO ACT: IMPROVING LIVER HEALTH AND OUTCOMES IN LIVER DISEASE]411 Kb

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