TBA (26S151)

An integrated clinic for patients with cirrhosis combining clinical evaluation, liver and spleen stiffness measurements and endoscopy: A new approach to cirrhosis care using Lean management principles

Author(s)

Eabha Ring 1, 2 , David Prichard 1, 2 , Lewel Alvarado 1 , Kimmy Villaluna 1, 2 , Noelia Justo Rubio 1, 2 , Noelle Cullen 1 , Issabele Pulcherio 1 , Collen Ray Arrogante 1 , Clodagh Quinn 1 , Finbar MacCarthy 1, 2 , Suzanne Norris 1, 2

Department(s)/Institutions

1 Department of Hepatology, St James's Hospital, Dublin, Ireland, 2 Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland

Introduction

At St James Hospital, 1,348 cirrhotic patients undergo biannual clinical review, phlebotomy, ultrasound, annual liver stiffness measurement (LSM), and periodic endoscopy. This substantial patient burden (e.g. missed work, childcare challenges) contributes to inefficiencies (e.g non-attendance) and impacts optimal patient care (e.g., repeated fasting and sedation exposure).

Aims/Background

We aimed to design, implement, and evaluate an integrated “single-visit” cirrhosis clinic to reduce patient burden and improve adherence to surveillance.

Method

A multidisciplinary steering committee comprising hepatology, endoscopy, nursing, medical physics, and administrative stakeholders co-designed the integrated clinic. The intervention consolidated LSM, spleen stiffness measurement (SSM), phlebotomy, unsedated transnasal endoscopy (TNE), and clinical review into a single visit. The project was registered with the Quality Improvement department. Pre-attendance patient engagement included written information and telephone contact. Iterative refinement was undertaken using Plan–Do–Study–Act (PDSA) cycles to optimise workflow, clinic layout, and patient throughput. Due to resource constraints, ultrasound was not included in this phase.

Results

122 patients attended the clinic; 91 (75%) completed all five components. Non-attendance rate was 5%, compared with 18% in standard care pathways. Completion rates were high for LSM (99%) and SSM (94%). TNE was well tolerated but 12 patients (10%) required subsequent sedated endoscopy and one declined the procedure. Varices were identified in 31% of patients, 39% of which were classified as high-risk. Eligible patients were commenced on non-selective beta blockers. Over four months, the integrated model reduced total hospital attendances and patient contact by 80% (610 vs 122).

Conclusions

Implementation of a multidisciplinary, integrated cirrhosis clinic significantly improved care efficiency, reduced non-attendance, and enabled same-day risk stratification and treatment initiation. This patient-centred model minimises burdens such as repeated visits, fasting, and sedation exposure while enhancing hospital resource use. Future PDSA cycles will focus on incorporating ultrasound for hepatocellular carcinoma surveillance and evaluating long-term clinical outcomes.