Cirrhosis Care Alberta (CCAB): A Pragmatic Type II Hybrid Effectiveness Implementation Trial
Cirrhosis Care Alberta (CCAB): A Pragmatic Type II Hybrid Effectiveness Implementation Trial
Liver cirrhosis is the leading cause of morbidity and premature mortality in patients with
 digestive disease. There are many gaps in care which contribute to a high rate of hospital
 readmissions (44 percent at 90 days) and inadequate quality of care. Currently, there is a
 lack of structured processes to initiate best practice support for medical and broader health
 needs of high risk patients.

 The cirrhosis care Alberta program (CCAB) is a 3 year multi-component quality improvement
 initiative which will aim to improve quality of care, reduce acute care utilization and be
 satisfactory to both patients and providers. Best practice support will be provided in the
 areas of: Evidence based management of cirrhosis, alcohol use support, frailty, advance care
 planning, home-hospital-home transitions including standardized outpatient monitoring and
 structured urgent access for rapid, on-demand outpatient assessment.
Cirrhosis Care Alberta (CCAB) is a 3 year multi-component system-wide quality improvement
 trial which aims to improve quality of care, reduce acute care utilization and meet the needs
 of both patients and providers throughout Alberta. Instead of addressing just a single
 contributor to acute care utilization, this ambitious intervention will be the first in the
 world to bring together care providers across the province to tackle the complex multilevel
 problem with a multilevel solution. The intervention includes implementation of our
 standardized integrated strategy for delivering evidence-based best practices under
 real-world conditions to address the key determinants of hospital readmission and length of
 stay (LOS) in patients admitted with cirrhosis.

 The CCAB project intervention includes:

 1. Comprehensive Care Bundle (development underway):

 1. Admission and Discharge/Transition order set focused on the screening and
 management of:

 -  Cirrhosis complications

 -  Frailty and malnutrition

 -  Alcohol use disorder and

 -  Transition to community

 2. Patient and caregiver education

 • A major theme that came up in focus group work with patients and in the
 literature is the lack of useful information that is available to them. This is a
 top priority for patients. Education will include guidelines and tools for patients
 to improve self-management as well as support for caregivers.

 3. Provider education

 -  Nursing education focused on providing teaching to patients with cirrhosis and
 initiating alcohol screening and performing a brief intervention to promote
 abstinence is done in the minority of patients at discharge.

 -  Physician education focused on cirrhosis complications and broader health
 needs such as prescribing pharmacological therapies for alcohol use disorder
 (currently done in <5% of patients even though the number needed to treat is
 12 (i.e. need to do it in 12 patients to result in a benefit)).

 2. Community Care Pathways

 1. Hepatic Encephalopathy (HE) Pathway: HE is the most common reason for admission to
 hospital and is a significant burden on patients and families. In collaboration
 with Health Link, this project aims to develop a call pathway so that patients and
 families can receive best practice support by nurses in the community and avoid
 needing to access emergency departments when HE can safely be managed in the
 community. The patient education surrounding HE is being developed as part of the
 Care Bundle, but developing a care pathway will ensure the education is translated
 and reinforced.

 2. Ascites Pathway: Ascites (abdominal fluid build-up) is the most common cirrhosis
 related complication and is extremely uncomfortable for patients. When diuretics
 are not tolerated or ineffective, this population typically requires frequent
 draining of the ascites fluid (paracentesis) to treat symptoms such as shortness of
 breath, pain and inability to eat. Paracentesis is usually performed in hospital
 based day procedure areas, but when patients can not access a scheduled
 paracentesis in a timely manner, they are left with no option other than going to
 emergency rooms. Through process mapping and identifying current barriers and
 facilitators with each site, the project team aims to develop effective pathways
 for linking patients in with timely paracentesis.
Inclusion Criteria:

 -  Adults (great than 18 years of age) with a clinical diagnosis of cirrhosis (confirmed
 by compatible radiology, histology or fibroscan)

 -  Admitted to a study hospital site

 Exclusion Criteria

 o Adult patients who do not have cirrhosis