HEALTHCARE DELIVERY Key recommendations
Definitive eradication of gallstones prevents the risk of a recurrent attack of acute pancreatitis. This usually involves cholecystectomy (surgical procedure to remove a gallbladder) and ensuring that no stones remain in the bile duct. For those patients with an episode of mild acute pancreatitis, early surgery, as outlined above, should be undertaken, either during the index admission, as recommended by the International Association of Pancreatology (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.
Given the increasing complexity of the management of acute pancreatitis and its multidisciplinary nature, formal networks should be established so that every patient has access to specialist interventions, regardless of which hospital they present to and are initially managed in. Indications for when to refer a patient for discussion with a specialist tertiary centre and when a patient should be accepted for transfer, should be explicitly stated. Management in a specialist tertiary centre is necessary for patients with severe acute pancreatitis requiring radiological, endoscopic, or surgical intervention. For all early warning scores and as recommended by the Royal College of Physicians of London for NEWS, all acute hospitals should have local arrangements to
ensure an agreed response to each trigger level including: the speed of response, a clear escalation policy to ensure that an appropriate response always occurs and is guaranteed 24/7; the seniority and clinical competencies of the responder; the appropriate settings for ongoing acute care; timely access to high dependency care, if required; and the frequency of subsequent clinical monitoring. Antibiotic prophylaxis is not recommended in acute pancreatitis. All healthcare providers should ensure that antimicrobial policies are in place including prescription, review and administration of antimicrobials as part of an antimicrobial stewardship process. These policies must be accessible, adhered to and frequently reviewed with training. NCEPOD chair, Professor Lesley Regan, explained that Treat the Cause is the first large scale assessment of the quality of care delivered to patients suffering from acute pancreatitis that has ever been performed in the UK.
“My initial impression was that this was a good news story because a sizeable proportion of patients received good care during a time when we often hear how badly the NHS treats patients because of reduced resources. However, as with most NCEPOD reports, more detailed scrutiny reveals that the true picture is more complex. As a result my second impression is that there are many aspects of care in which we could be doing a lot better. Our report has been able to identify these and
make some practical suggestions to improve the situation.”
She said that a key finding in the report stood out to her: “The two-thirds of patients admitted to surgical wards with acute pancreatitis, 85% of them – the majority – continued under the care of a surgeon. This reflects the seriousness of the condition, and that in the majority of cases it is an acute abdominal emergency. Many of the patients have developed the acute disease because of gallstones. Nevertheless, our report found that only 19% of patients with gallstone pancreatitis had surgery, which means that a large number of acute admissions did not have surgery when they should have. “So, my first report as NCEPOD chair,
Treat the Cause, strikes me as having many of the themes that will be familiar to readers of the last few years. We are not doing the simple things either as well or as consistently as we should do them. We should and can do better for our patients.” To access the full report, visit:
www.ncepod.org.uk References
CSJ
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.
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