Success Story: Enhancing Specialist Care for Patients with Decompensated Liver Disease

Physicians often see opportunities for improvements to patient care in the course of their practice. Dr. Rohit Pai (Gastroenterology) and Dr. Brian McArdle (Internal Medicine) saw one when treating patients living with decompensated liver cirrhosis. This complex patient population present frequently at the emergency room for treatment, and require regular follow up assessments, blood work, endoscopy, imaging, and paracentesis. In the interest of preserving emergency room care for truly acute illness, and to provide a better standard of care for their patients, Dr. Pai and Dr. McArdle set out to design a better pathway for regular care.

Drawing on consecutive grants from the Physician Quality Improvement and South Island Medical Staff Association’s Facility Engagement funding, they broke down this ambitious plan into smaller discrete projects over the past few years. First, they conducted a review of all patients with liver disease who had undergone a therapeutic paracentesis over a 12-month period. This identified a subgroup of patients who could benefit from specialized care with gastroenterologists and internal medicine physicians, in collaboration with primary care and addictions medicine colleagues.

Liaising with this group of clinicians highlighted the value of caring for these patients concurrently through Internal Medicine and Gastroenterology. Dr. Pai and Dr. McArdle, along with Resident Jeremy Murray-Guenther, launched an informal pilot of this process and have seen approximately 12-15 patients through this concurrent care model. By conducting a regular chart review of these patients, they have seen a measurable reduction in hospital admissions and hospital length of stay as a result of this new care plan.

Throughout this process, the team worked closely with Cheryl Armstrong and Dr. Alan Buckley through the Medicine Quality Council (MQC) to help navigate the various supports within Island Health to ensure the greatest chance of success for their project objectives. “It’s difficult to know who to approach to get help from sometimes”, said Dr. Pai. “Working with Cheryl and Al is one of the reasons we knew who to approach, and how to navigate the system”. Another strength identified by Dr. Pai was having a co-physician lead on the project, Dr. McArdle, who also performs administrative duties as the Site Medical Director for Royal Jubilee Hospital.

This project has recently secured funding support from the Health System Redesign (HSR) program to work with Island Health colleagues to formalize the concurrent model of care, get access to regular nursing staff for the clinic, and secure some space through medical daycare. Continuing to track their results through RedCap will ensure that the project is rigorously evaluated. Support from the HSR program will also enable the group to connect with physicians across Vancouver Island to harmonize the protocols around paracentesis patients, to ensure consistent care. In the future, the group would like to develop a Central and North Island Liver Clinic.

These goals may seem ambitious, but it is the steadfast and collaborative approach of the team that has enabled them to achieve their aims thus far. Dr. Pai credits the broad array of specialists – gastroenterology, internal medicine, emergency medicine, and radiology – who were involved as key to their success. Also crucial was identifying a simple question at the outset. “Only bite off as much as you can chew”, says Dr. Pai.

We celebrate this team’s achievements to date and look forward to following their progress within the Health System Redesign program over the coming months.

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