HEALTHCARE DELIVERY
complex imaging where the cause remained obscure, a larger number of patients could have undergone treatment to prevent recurrence of their pancreatitis.” He said that this report had again revealed the inconsistent use of early warning systems in hospitals and called for early warning scores to be a national priority: “We found examples where some hospitals used different scoring systems across the same hospital. “This is not the first time that NCEPOD has identified how important it is to use early warning systems to monitor the severity of a patient’s illness. This is essential to allow early identification of any deterioration in the patient’s condition. Only last year our report into sepsis called for a single national system to be introduced to all hospitals and GP surgeries such as the National Early Warning Score (NEWS). This must be a priority.” Key findings included:
l Gallstones were the most common identified cause of acute pancreatitis in 46.5% (322/692) of patients. In 22% (152/692) of patients it was alcohol excess, and in 17.5% (121/692) no underlying cause of the acute pancreatitis had been identified.
l 20.6% (143/692) of patients included in this study had one or more previous episode of acute pancreatitis.
l In 93% (121/130) of the patients readmitted for recurrence of AP the cause was the same as their previous admission.
l Although the initial assessment was deemed prompt in the majority of patients it did not include any form of early warning score in 30.7% (154/502) of emergency department admissions for acute pancreatitis.
Review of quality of care Number of patients
Lipid profile Triglycerides
Clotting screen
Arterial blood gases Serum calcium Glucose
Group and save ECG
Chest x-ray
C-reactive protein Lipase
Troponin Amylase
Liver function tests Table 1
l In one-fifth of cases the use of antibiotics was not considered appropriate.
l In one-fifth (21%; 44/209) of patients no reason was given for not performing an ultrasound test.
l Only 19% (61/322) patients with acute pancreatitis caused by gallstones had gallstone surgery during their admission. NCEPOD reviewers stated that 37% (53/143) of 179 patients who did not undergo early surgery (definitive treatment) should have done so.
l 80% (133/166) of hospitals reported having some form of onsite alcohol liaison service. For patients who had a documented previous admission with acute pancreatitis associated with alcohol
excess, the clinicians caring for these patients could only confirm that a referral had occurred to an alcohol liaison service in 51% (28/58) of patients.
l Only 28/114 (24%) hospitals without out-of-hours access to radiological drainage for pancreatic collections stated that they were part of a formal network to provide this care. The remainder said that they relied on “informal networks” and “local goodwill”. Fourteen hospitals clearly stated that they had no arrangements in place to provide radiological drainage.
l Only approximately 1/3 of hospitals in the current study reported being part of a formal regional care network for acute pancreatitis.
Are patients being screened for osteoporosis?
At the recent annual meeting of the British Society of Gastroenterology, the results of a study presented by Menabawey et al, from the Royal Free NHS Trust,1
highlighted the
need to improve the screening of patients with pancreatitis to prevent avoidable fragility fractures. Presenting the results of a study on care for patients with chronic pancreatitis, experts from the Royal Free NHS Trust explained that one of the common complications of the condition is osteoporosis – patients have double the risk of fragility fractures compared with the general population. The National Institute of Clinical Excellence (NICE) guidance recognises chronic pancreatitis as a significant risk factor and recommends that all patients aged 50 or over should be considered for DEXA scanning if they are deemed at risk.2
The purpose of the study
was to assess whether patients under review for chronic pancreatitis were being referred for DEXA scanning and to pick up
the rate of fragility fractures. The retrospective analysis included patients who were identified as having chronic pancreatitis and were undergoing outpatient review at a large NHS Hospital Trust in North London. The team reviewed their records and imaging to assess if they had ever been referred for a DEXA scan and whether they had radiological evidence of a fragility fracture.
Of 106 patients identified, only one (0.94%) was referred for DEXA scanning, which did confirm osteoporosis. This patient had been referred incidentally
by a GP for another reason not pertaining to their chronic pancreatitis. 14 patients (13.21%) had sustained low impact fractures (five hip, three vertebral, three wrist, two distal fibula, one elbow). Of these fractures, six (42.9%) had been on no bone protection at all, six (42.9%) had been on calcium and vitamin D supplementation, and two (14.3%) had been on a bisphosphonate.
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The authors concluded that despite chronic pancreatitis being a well- recognised risk factor for osteoporosis, the investigation and active mitigation of its risk by clinicians in the outpatient setting was poor. This may have resulted in potentially avoidable osteoporotic fractures. The authors recommended
that future studies should look at whether this is a wider phenomenon nationally and stated that risk assessment for osteoporosis should form a part of a routine clinical review in patients under follow-up for chronic pancreatitis.
References
1 T. M. El Menabawey, S. Phillpotts, R. Preedy, K. Besherdas, Barnet Hospital, Royal Free NHS Trust, Hertfordshire, How good are we at looking for osteoporosis in chronic pancreatitis? Abstract accessed June 2016 and presented at the BSG 2016 annual meeting.
2 NICE, Osteroporosis: assessing the risk of fragility fracture. NICE guidelines CG146. August 2012.
OCTOBER 2016
56 53 45 45 41 35 32 27 28 19 18 17 11 2 2
Appropriate investigations that were omitted but should have been done – clinicians’ opinion Missing investigations Lactate dehydrogenase
%
30.3 28.6 24.3 24.3 22.2 18.9 17.3 14.6 15.1 10.3 9.7 9.2 5.9 1.1 1.1
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