Mr Derek OReilly AP Acute pancreatitis Management crosses many specialties High mortality and morbidity Recurrent admissions Complex care and specialist input Varied implementation of guidelines ID: 933382
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Slide1
Dr Neil Smith
Dr Simon McPhersonMr Derek O’Reilly
#AP
Slide2Acute pancreatitis
Management crosses many specialtiesHigh mortality and morbidityRecurrent admissions
Complex care and specialist inputVaried implementation of guidelines
Slide3Study population inclusion criteria
Patients aged 16 years or older who were coded for a primary diagnosis of acute pancreatitis and admitted to hospital between 1st January and 30
th June 2014
An inpatient stay of three or more nights
Admission to critical care
Death in hospital
Slide4Data collection
Patient identifier spreadsheetClinician questionnaireCase notes/peer review
Organisational questionnaire
Slide5Data returns
Slide6Study aim
To identify remediable factors in the quality of care provided to patients treated for acute pancreatitis
Slide7CAUSE & PATIENT CHARACTERISTICS
Slide8Cause of AP – study population
Gallstones 46.5% (322/692)Alcohol excess 22% (152/692)Post-ERCP 4% (28/692)
No cause 17.5% (121/692)
Slide9Cause of AP by age
Median age = 61 years (17-99)
55% male
Slide10ADMISSION
Slide11Initial presentation
98.3% (687/699) Emergency
79% (551/698) Emergency department 21% (147/698) Directly to a ward or level 2/3
Slide12Ward admission
68.9% (483/701) SAU or surgical ward
9.4% HDU/ITU
Slide13Early warning scores
Slide14EWS in the emergency department
Slide15EWS in the emergency department
Slide16EWS on the ward
Slide17Early warning scores
65.1% (313/481) ED and ward EWS 8.7% (42/481) no EWS either location8% (22/285) different EWS
Slide18Escalation of care
93% (356/383) on going use of EWS
Most common
Critical care review
Other specialty review
Slide19Escalation of care
13% (15/115)
delayed review
Slide20Recommendation 4 - early warning scores
An early warning score should be used in the ED and throughout the patient’s hospital stay to aid recognition of deterioration. This should be standardised within and across all hospitals.
NCEPOD supports the use of NEWS to facilitate standardisation
Slide21Recommendation 5 - early warning scores
All acute hospitals should have local arrangements to ensure an agreed response at each NEWS trigger level including:
Speed of response
Clear escalation policy which ensures an appropriate response 24/7
Seniority and clinical competencies of the responder
Appropriate setting for on-going acute care and timely access to high dependency care if required
Frequency of subsequent monitoring
Slide22Oxygenation &
fluid management
Slide23Oxygenation and fluid management
Slide24Acute Kidney Injury
21.7% (148/681) AKI
6 avoidable
Slide25imaging
Slide26Imaging
Establish Diagnosis when clinical/biochemical doubt9.3% (39/418)Cause
Severe APConfirmation of severityDiagnose complicationsGuide treatmentsMonitor resolution
Slide27Ultrasound
Slide28No ultrasound
21% (44/209) no reason for no US
24/44 alcohol-related AP
Slide29Recommendation 9 - gallstones
Gallstones should be excluded in ALL patients, including those thought to have alcohol-related AP, as gallstones are common in the general population.
Abdominal US is the minimum that should be performed.
Slide30CT scans
60.1% (416/692) at least one CT
17.9% (73/408) necrotising pancreatitis
12.7% (52/408) APC or pseudo-cyst
13 infected collections
Slide31Omitted imaging
Slide32Recommendation 17 - AP of unknown cause
After excluding the commoner causes of AP those in whom the cause remains unknown should undergo MRCP and/or endoscopic ultrasound to detect micro-
lithiasis
,
neoplasms
and chronic pancreatitis as well as rare morphological abnormalities. A CT of the abdomen should also be considered.
Slide33Antibiotic use & misuse
Slide34Indication for antibiotic use
Slide35Appropriateness of antibiotics
Slide36Inappropriateness of antibiotics
Slide37Recommendation 7 - antibiotic prophylaxis
Antibiotic prophylaxis is not recommended in acute pancreatitis. All healthcare providers should ensure that antimicrobial policies are in place including prescription, review and the administration of antimicrobials as part of an antimicrobial stewardship process.
These policies must be accessible, adhered to and frequently reviewed with training provided in their use.
Slide38nutrition
Slide39Nutrition team availability
Slide40Nutritional assessment
Slide41Dietitian involvement
Slide42Dietitian involvement
Slide43Overall nutrition management
Slide44Recommendation 8 - nutritional support
All patients admitted to hospital with acute pancreatitis should be assessed for their overall risk of malnutrition. This could be facilitated by using the Malnutrition Universal Screening Tool (MUST) and provides a basis for appropriate referral to a dietitian or a nutritional support team and subsequent timely and adequate nutrition support.
Slide45The problem of
recurrent admissions
Slide46Previous admissions
Slide47Definitive gallstone management
Slide48Deferral of cholecystecomy
Slide49Availability of cholecystectomy
Slide50Recommendation 10 - gallstone pancreatitis
For those patients with an episode of mild acute pancreatitis, early definitive surgery should be undertaken, either during the index admission, as recommended by IAP, or on a planned list, within two weeks. For those patients with severe acute pancreatitis, cholecystectomy should be undertaken when clinically appropriate after resolution of pancreatitis.
Slide51Alcohol-related acute pancreatitis
Slide52Alcohol liaison service
Slide53Recommendation 13 - alcohol support
All patients with suspected alcohol-related acute pancreatitis should be discussed with the hospital alcohol support service at every admission.Efforts to deal with this underlying cause of acute pancreatitis should equal those of gallstone acute pancreatitis.
Future clinical guidelines on acute pancreatitis should incorporate this.
Slide54networks for the treatment of complications
Slide55Formal network of care
Slide56Informal network of care
Slide57Pancreatic drainage
Slide58Availability of specialist surgery
Slide59Interventions performed
Slide60Recommendation 16 - specialist centres
Specialist tertiary centres for acute pancreatitis should be commissioned. ...defined by the IAP as a high volume centre with intensive care facilities, daily access to radiological intervention, interventional endoscopy and surgical expertise in managing necrotising pancreatitis.
An example model to base this on could be the existing ‘Improving Outcomes Guidance’ compliant hepato-pancreato-biliary cancer units.
Slide61Outcomes & overall quality of care
Slide62Outcomes
Slide63Overall quality of care
Slide64Conclusion
Much good newsBut the full picture is more complex; there are many areas where we could be doing better
NCEPOD has identified these and produced recommendations for improvement
Slide65THANK YOU
www.ncepod.org.ukTo download the report
#AP