Nursing

Abstract

181

A clinical nurse specialist comprehensive hepatology clinic: Streamlining service delivery

Marcelle Perrin, Crystal Connelly, Vanessa Sheehan and Ying Shen

Fiona Stanley Hospital, Murdoch, Australia

Background: Advances in curative therapies for Hepatitis have seen the core role of the hepatology specialist nurses broaden significantly. In addition, hepatology service demand is increasing across both inpatient and outpatient settings. Transitioning to a new health service provided an opportunity to implement an alternative model to streamline access to hepatology services. A team of Hepatology Clinical Nurse Specialists deliver a clinic service to all hepatology patients aimed at managing extensive waitlists and ensuring appropriate services are provided in the timeliest manner. There is limited literature available on nurse-led hepatology clinics that are not condition specific. This clinic is the only one of its kind in Western Australia and, to our knowledge, nationally.

Service structure and implementation: The clinic is autonomously led by a team of three Clinical Nurse Specialists and aims to divert from the Consultant waitlist where appropriate, provide baseline hepatology assessment including investigations and liver scan to facilitate early intervention and inform timely delivery of care, and improve the hepatology patient experience. A guideline and suite of standard operating procedures were developed and endorsed by the health service. Medical governance review is provided at weekly multidisciplinary team meetings. Patients are initially referred from Consultants or General Practitioners (GP) or identified through a virtual assessment triage of waitlisted patients. Hepatology screening and assessment is undertaken by a Hepatology Clinical Nurse Specialist and patients are either discharged from the service to the care of their GP, remain on the Consultant waitlist for review, or engage in ongoing monitoring and education within the clinic.

Service delivery outcomes: Since implementation in 2022, the clinic has provided over 5,000 occasions of care. In the preceding year the clinic has had 195 referrals, with the primary sources of patient referrals being GPs (45%) and specialists (40%). The largest proportions of the cohort present due to deranged liver function tests (40%), followed by steatosis (29%). Seventy three percent of individuals referred engaged with the clinic service. Post assessment and clinic visit patients are most commonly identified to be suffering steatotic liver disease and are provided counselling and education. Half of presenting patients are discharged from the service to the care of their GP, resulting in a significant reduction to the waitlist for Consultant review. Ongoing surveillance is maintained for 40% of the presenting cohort. The service generates over $400,000 in activity-based funding per year to support ongoing service delivery.

186

A community-based MASLD care pathway for people with type 2 diabetes: barriers and considerations

Melanie Aikebuse², Lucy Gracen¹, Babak Sarraf¹⁰, Steven McPhail⁵, Anthony Russell⁶, James O'Beirne⁷, Katharine Irvine⁸, Suzanne Williams⁹, Patricia Valery⁴ and Elizabeth Powell^2,3,4

¹Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Herston, Australia; ²Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia; ³Centre for Liver Disease Research, Faculty of Medicine, Translational Research Institute, The University of Queensland, Woolloongabba, Brisbane, Australia; ⁴QIMR Berghofer Medical Research Institute, Brisbane, Australia; ⁵Australian Centre for Health Services Innovation School of Public Health, Insitute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia; ⁶Endocrinology and Diabetes, the Alfred Hospital, Melbourne, Australia; ⁷Department of Gastroenterology and Hepatology, Sunshine Coast University, Birtinya, Australia; ⁸Mater Research, Translational Research Institute, Brisbane, Australia; ⁹Inala Primary Care General Practice, Inala, Australia; ¹⁰Department of Gastroenterology, The Townsville Hospital, Townsville, Australia

Background and Aim: Concern is rising over future burden of cirrhosis from metabolic dysfunction-associated steatotic liver disease (MASLD). This study focused on type 2 diabetes (T2D), a population with high prevalence of MASLD (40-70%). Current guidelines recommend use of Fibrosis-4 score (FIB-4) as the first step in non-invasive fibrosis risk stratification. However, FIB-4 has low accuracy classifying low risk fibrosis in patients with T2D. We aimed to examine: (1)feasibility of providing T2D patients with a ‘liver health check’ using FibroScan as the first step to identify at-risk patients needing referral for specialized care; (2)General practitioner (GP) response to study letters with recommendations regarding management in the primary care setting.

Methods: Sequential participants recruited from community diabetes clinics and GPs were invited to participate in the study. Participants received a liver health check including FibroScan and were advised to see their GP to discuss the results. MASLD diagnosis and presence of clinically significant fibrosis was based on CAP score ≥248db and liver stiffness measurement (LSM) ≥8kPa respectively. Summaries of study visits, including FibroScan results were provided to participants’ GPs. Study letters contained key results, their interpretation, advice about management of cardiometabolic risk, patient follow-up, and referral criteria. To evaluate effectiveness of the letters, a questionnaire was sent to participants’ GPs to determine their response to guidelines and recommendations.

Results: 543 patients attending diabetes clinics were invited to participate and a further 95 patients were referred directly from their GP or self-referred. 302 participants completed the liver health check during 2021-2023. 62 (21%) participants had recommendations for referral to a tertiary liver clinic: 45 (15%) with LSM ≥8kPa, 15 with ‘red flags’ (e.g. thrombocytopenia) and 2 with unsuccessful FibroScan assessments. Of concern, 29 of the 45 patients with LSM ≥8kPa had a low FIB-4 score (Figure). A referral from GPs to the tertiary liver clinic was received for 27 (44%) of the 62 participants. Approximately 90% of GPs had a positive response to the study letters and recommendations.

236

A nurse-led community-based program in chronic liver disease enables optimisation of medical interventions and prevents complications following hospitalisation

Kristen Peake¹, Leya Nedumannil¹, Vanessa Lowen¹, Kendall Fitzpatrick¹, Catherine Yu¹, Mayur Garg^1,2, Diana Lewis¹ and Siddharth Sood^1,2

¹The Northern Hospital, Melbourne, Australia; ²The University of Melbourne, Melbourne, Australia

Background and Aims: Management of chronic liver disease (CLD) requires a comprehensive multidisciplinary approach to address the complex needs of this patient population. Readmission rates for patients with CLD remain high. Liver at Home (L@H) is a 12-week program designed to bridge the gap in care, with hepatology clinical nurse consultants (CNCs) providing consultations at patients' homes following discharge from hospital. L@H focusses on the effectiveness of home visits and how they impact patient outcomes compared to traditional outpatient review methods. We evaluated the type, frequency and outcomes of reviews, including management changes implemented as a direct result of L@H.

Method: CLD inpatients residing within a tertiary health service's catchment admitted under Gastroenterology with liver-related conditions between 1/3/23–1/3/24 were enrolled into L@H. Patients who declined participation or deemed high-risk on the ‘Safe Home Visit Risk Screening Tool’ were excluded. Patients typically received three visits per week for the first 4 weeks, followed by weekly visits for 8 weeks (clinically dependent). Analysis explored L@H discharge support including medication adjustments, initiation of regular albumin infusions, arrangement of abdominal paracentesis, and referrals to other health/emergency services.

Results: 67 patients [37% (n = 25) female, median age 61 (interquartile range 45–71) years] were enrolled in L@H, of whom 8 patients were enrolled more than once (due to hospital readmission). Of these, 28 (41.8%) were discharged early due to poor engagement (n = 14) or unexpected hospital admission (liver or non-liver related) (n = 14). A total of 719 clinical encounters were performed, with over half (389, 54.1%) delivered face-to-face in patient's homes. Hepatology CNCs assessed fluid status, encephalopathy and general wellbeing at each visit, focusing on education including review of lifestyle habits and adherence to low salt/high protein diet. Medications were adjusted in 122 (16.9%) visits, most commonly for diuresis (76, 45.2%) and encephalopathy (25, 20.4%). Physical review of fluid status, including ascites assessment, led to initiating regular albumin infusions in 10 (14.9%) patients and organising large volume paracentesis in 14 patients. 11 patients (16.4%) were referred to outpatient dietitians for nutritional optimisation, and 9 reviews (1.25%) led to emergency medical intervention.

Conclusion: L@H is an innovative program that enables ongoing hepatology CNC care following hospitalisation, leading to significant clinical changes and optimisation of management of liver-related complications in the community. These findings provide the foundations for future prospective studies to analyse the healthcare benefits of specialist home-based liver care programs, especially given the rising health burden of CLD.

248

Strong engagement with home-based liver nurse-led management following discharge from hospital in patients with chronic liver disease

Leya Nedumannil¹, Catherine Yu¹, Kristen Peake¹, Vanessa Lowen¹, Kendall Fitzpatrick¹, Mustafa Mohamedrashed¹, Mayur Garg^1,2, Siddharth Sood^1,2 and Diana Lewis¹

¹The Northern Hospital, Epping, Australia; ²The University of Melbourne, Parkville, Australia

Background and Aim: Patients with chronic liver disease (CLD) are often psychosocially complex with limited access to integrated multidisciplinary outpatient care. Liver At Home (L@H) was initiated to bridge this gap by extending specialist nursing support into the community through regular home and telehealth reviews for 3 months following hospital discharge. We aimed to evaluate patient engagement with this program and assess predictors of poor engagement.

Methods: Patients enrolled to L@H on hospital discharge between 01/03/2023 and 01/03/2024 were divided into the “engaged group” and “disengaged group”. Re-enrolments to L@H within this period were included. The engaged group encompassed those who completed all 3 months of L@H (“completed L@H"), and those who prematurely discontinued L@H involuntarily due to long hospital readmission (“incomplete L@H"). Disengagement was classified as failure to participate in home/telehealth visits on ≥ 3 occasions, or patient refusal of further visits. Admission back to hospital within 0–7 days of initial hospital discharge was defined as a failed discharge, whilst 8 days-3 months was defined as a readmission. Patient demographic and clinical characteristics were compared between the engaged and disengaged groups.

Results: Overall there was excellent engagement with L@H. Of the 67 CLD patients who were enrolled to L@H, 79% (53/67) engaged well with the program [58% (n = 39) completed L@H, 21% (n = 14) incomplete L@H], leaving 21% (n = 14) who disengaged. The disengaged group was significantly younger (P = 0.001), with a higher proportion born outside Australia (P = 0.03) and with alcohol-related CLD (P = 0.01) (Table 1). Median MELD-Na score appeared higher in the disengaged group (22 vs. 17, P = 0.15). Whilst the disengaged and engaged groups had similar 3-month all-cause hospital readmission [29% (n = 4) vs. 53% (n = 28), P = 0.11], all (n = 4) readmissions in the disengaged group were liver-related, compared to 61% (n = 17 out of 28) in the engaged group, P = 0.27.

Conclusion: In this single-centre study, a high level of engagement with L@H was observed amongst recently hospitalised CLD patients, with almost 80% engaging well. We identified younger age, birth outside Australia, and alcohol-related liver disease as predictors of disengagement from the program. These findings from the first year of L@H suggest that despite the psychosocial complexities which tend to afflict this patient cohort, many CLD patients and their carers are motivated to partake in home-based specialist liver nurse management to optimise their health. Whilst good engagement with L@H may have had an associated benefit in reducing the proportion of liver-related readmissions, larger numbers are required to evaluate differences in hospital readmission between engaged and disengaged patients.