Acute pancreatitis: fifth of patients suffering potentially preventable repeat admissions, report finds
Published: 04 Jul 2016
Patients with acute pancreatitis (AP) suffer preventable, repeat admissions to hospital because the cause of their pancreatitis has either not been diagnosed or not been treated, the latest report delivered by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) for the Medical and Surgical Outcome Review Programme reveals.
In one in five cases (143/692) patients had had one or more previous episodes of AP and in 93% of these (121/130) the cause of readmission with AP was the same as it had been previously, according to the study (commissioned by HQIP as part of the Clinical Outcome Review Programme).
Acute pancreatitis patients suffer severe pain that is caused by inflammation of the pancreas. It affects young and old, and in just one six-month period in 2014 over 14,000 people were admitted to hospital with AP. NCEPOD identified that gallstones were the most common cause (46.5%; 322/692) of AP, and for 22% (152/692) of patients it was alcohol excess. In 20% of cases it is very likely patients will develop a severe form of the disease and be at risk of death, and when this happens they will need critical care support and a prolonged stay in hospital.
Report co-author and NCEPOD clinical co-ordinator Derek O’Reilly said that the report found a worryingly high number of repeat admissions where the cause of AP had been the same as it had been in the previous admission to hospital. He warned: “The majority of patients are admitted to hospital with gallstones, and the failure to clear them completely results in unacceptable rates of readmission with recurrent pancreatitis and other gallstone-related complications.”
“Repeat hospital stays would be reduced significantly if patients with mild acute pancreatitis had surgery to remove gallstones within two weeks of admission.”
Derek O’Reilly highlighted antibiotic overuse: “We have to avoid inappropriate antibiotic prescription, and our report found that 20% of the patients in the study had been given antibiotics unnecessarily. It is ineffective in the early stages of AP, encourages the growth of resistant strains of bacteria, and wastes NHS resources.”
He also highlighted concerns about how hospitals care for AP patients with alcohol problems: “Where alcohol misuse was associated with AP we found that only half (51%; 28/52) of the patients reviewed were referred to an alcohol liaison service, despite 80% of hospitals in the study having onsite services. Clinicians are missing a significant opportunity to change the future quality of life for patients by helping them to stop harmful levels of drinking, and importantly prevent AP reoccurring.”
Report co-author and NCEPOD clinical co-ordinator Simon McPherson said: “We found in too many cases of acute pancreatitis clinicians never found the underlying cause (17.5%; 121/692) of the illness. If ultrasound scans had been used to detect gallstones, for example, along with more 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.”
- 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
- 20.6% (143/692) of patients included in this study had one or more previous episode of acute pancreatitis.
- In 93% (121/130) of the patients readmitted for recurrence of AP the cause was the same as their previous admission
- 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
- In one-fifth of cases the use of antibiotics was not considered appropriate
- In one-fifth (21%; 44/209) of patients no reason was given for not performing an ultrasound test
- 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
- 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
- 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
- Only approximately 1/3 of hospitals in the current study reported being part of a formal regional care network for acute pancreatitis
- 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, Prof 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.”