Introduction

A clinical assessment service (CAS), was introduced replacing choose and book for primary care referrals. The CAS service involves assessment of referrals letters from primary care and triaging to see consultants in the outpatient department (OPD), or arranging diagnostic investigations and a virtual review of the investigations to decide on the management plan thereafter.

Aims & Methods

We describe the initial experience of this new service with aims to enhance the patient pathway, reduce unnecessary outpatient appointments and speed up diagnosis and treatment.
A single centre, retrospective analysis of all routine OPD referrals to the gastroenterology department at a district general hospital in North London triaged via CAS from January to end December 2022, were scrutinized. During this period, 1-2 CAS clinics (24 patients triaged per clinic)/week was undertaken. Triage outcomes included : straight to test (STT), clinic review, redirect to an alternative service or discharge back to GP. A template outcome letter was sent to GPs and patients.
Electronic Patient Record (EPR) was interrogated for : reason for referral, triaging outcome, investigations requested, and investigation outcomes.

Results

2265 patients were assessed.
CAS triage outcomes were : 680 patients (30%) were triaged to receive an OPA; 68 patients (3%) were redirected to another service. 20 patients were discharged back to their GP, having already been investigated for the same indication by another department. The remainder were sent for an investigation.
The commonest investigations were : gastroscopy (684), colonoscopy (288), combined gastroscopy and colonoscopy (171), CT scan (198), MRI (45).
959 patients (42%) required a first OPA either from point of triage or after they have had an initial STT investigation.
973 patients (43%) were discharged from the pathway following STT without requiring a clinic appointment.

The most common reasons for referral were: abdominal pain, dyspepsia, reflux symptoms or diarrhoea.

Conclusion

From this study we conclude, CAS model helps streamline the patient pathway with nearly 70% of patient triaged STT without requiring an OPD appointment. 43% of patients were discharged back to care of their GP after investigations without the need for an OPD appointment increasing capacity for OPD appointments. We endorse the use of this model of care for gastroenterology patients referred within the routine pathway.

Introduction

Guidelines for tissue sampling have been published by The European Society of Gastrointestinal Endoscopy (ESGE) on colitis. They recommend in patients with clinical signs and endoscopic signs of colitis, performing segmental biopsies (at least two from each segment), which should be placed in different specimen containers (ileum, caecum, ascending, transverse, descending, and sigmoid colon, and rectum). The ESGE recommends pancolonic dye-based chromoendoscopy or virtual chromoendoscopy with targeted biopsies of any visible lesions during surveillance endoscopy in patients with inflammatory bowel disease. ESGE also recommends that, in patients with known ulcerative colitis and endoscopic signs of inflammation, at least two biopsies be obtained from the worst affected areas for the assessment of activity or the presence of cytomegalovirus.

Aims & Methods

We aimed to observe clinical practice and compare these to the ESGE guidance in patients attending endoscopy for colitis.
A single centre, retrospective of patients with colitis attending endoscopy at a district general hospital was performed. 50 consecutive patients with new diagnosis of colitis, 50 consecutive patients with colitis for surveillance, and 20 consecutive patients with colitis for assessment of severity of activity were studied. Findings from clinical practice observed was scrutinised and compared to ESGE guidance. Data was obtained from the endoscopy reporting tool (unisoft) and from the electronic patient records.

Results

32 of the 50 patients (64%) with endoscopic signs of colitis followed guidance on biopsy protocol as per ESGE. In this study, the caecal intubation rate was 94%, with terminal ileal intubation rate of 80%. In this group 25/50 (50%) the colitis activity was documented by way of either the Mayo score or Ulcerative colitis endoscopy index of severity.
29 of 50 patients (58%) with colitis having a surveillance colonoscopy followed the ESGE biopsy protocol. 4 of 50 patients (8%) had chromoendoscopy as part of their colonoscopic surveillance procedure.
17 of 20 patients (85%) biopsies assessed for activity of colitis had biopsies. 7 of 17 patients (41%) having a biopsy had a comment regarding CMV inclusion bodies on histology. The histology request form specifically asked for assessment of CMV inclusion bodies in 5 of 17 patients (29%).

Conclusion

From this study of clinical practice of patients attending endoscopy for colitis, either in terms of new diagnosis, surveillance, or for colitis severity assessment with presence of CMV, the tissue sampling protocol of the ESGE is poorly implemented. We recommend improved dissemination of the guidelines within the endoscopy department to improve practice. Specifically asking for CMV inclusion bodies to histopathology on the request form may increase its assessment.

Introduction

Liver transplant is the only definitive treatment for chronic liver disease (CLD). Referral to a hepatologist for consideration for liver transplant should be made when a patient with CLD experiences a hepatic decompensation or has a MELD score ≥ 15. Failure to refer in a timely manner can result needing a liver transplant evaluation (LTE) in the inpatient setting while a patient is experiencing acute decompensation.

Aims & Methods

We aimed to compare the clinical presentation of patients undergoing LTE in the inpatient setting versus the outpatient setting to identify potential risk factors for requiring urgent evaluation. A list of all LTEs performed at our institution between 10/2017-8/2021 was obtained. Medical records were preliminarily reviewed for evaluation setting (Inpatient vs. Outpatients); evaluations for re-transplantation and acute liver failure were excluded. After all Inpatients (n=159) were identified, Outpatients (n=159) were selected at random to create a sample matched for age, gender, race, and ethnicity (n=318). Data were collected using our institutions electronic medical record and outside health records as obtained during LTE process. “Prior decompensations” refers to the number of the following clinical decompensations experienced prior to the time of LTE: ascites, hepatic encephalopathy (HE), variceal/acute UGIB, SBP and HRS. Categorical variables and continuous were compared between using Fisher’s Exact test, and student’s T test, respectively.

Results

Alcohol was the most common CLD etiology (42.1% Inpatient, 48.4% Outpatient). Inpatients tended to live further from our center than Outpatients (p=0.079). Inpatients had significantly higher MELD-Na scores (27.1 ± 8 vs. 13.3 ± 6; p<0.0001). Malnutrition was more common in 5.6 times more common in inpatients than outpatients (OR 5.6, 95% CI 2.9-10.8, p<0.001).. A similar proportion of patients had 1 hospitalization. But inpatients were 3 times as likely to have had ≥ 1 liver-related hospital admission prior to LTE (p<0.0001). Inpatients had significantly more prior decompensations than Outpatients prior to inpatient LTE (3.2 ± 1.4 vs. 1.8 ± 1.1, p<0.001), with the greatest differences in SBP and HRS.

Conclusion

Multiple liver-related hospitalizations and malnutrition may be considered a risk factor for ultimately needing inpatient LTE and should be taken seriously by health care providers caring for patients with CLD. Episodes of SBP and HRS should prompt providers to consider immediate or urgent LTE referral regardless of other factors.

References

Multiple liver-related hospitalizations may be considered a risk factor for ultimately needing inpatient LTE and should be taken seriously by health care providers caring for patients with CLD. Episodes of SBP and HRS should prompt providers to consider immediate or urgent LTE referral regardless of other factors.

Disclosure

D Devuni has received grant funding from Sequana Medical and receives grant support from the NIAAA (AA017986-11), both for research unrelated to this work.