Evidence Based Practice for Reducing Hospital Readmission for Cirrhosis Ryan Compton Nur 140 Denise Brents 11/06/2018 Evidence Based Practice for Reducing Hospital Readmission for Cirrhosis Hospital readmission is costly and time consuming for any condition

Evidence Based Practice for Reducing Hospital Readmission for Cirrhosis
Ryan Compton
Nur 140
Denise Brents

Evidence Based Practice for Reducing Hospital Readmission for Cirrhosis
Hospital readmission is costly and time consuming for any condition, nurses must take great care to educate their clients and recognize potential barriers that may prevent the client from following the guidelines established by the nurse during care. One condition that has a very high readmission rate is cirrhosis of the liver, with a readmission rate of 53% within 90 days (Bajaj, 2016). Cirrhosis also is the 2nd most deadly digestive disease and the 12th most common cause of death in the US (Seraj 2017). The most common reasons for readmission included nonadherence to medication/clincal outpatient visits, and comorbidity with other diseases such as diabetes and renal disorders. 37% of all readmissions in this 2017 study costed over 20000 dollars, making prevention of readmission a large priority for all patients (Seraj 2017). Important things that the nurse must educate the client on include: measures to eliminate consumption of alcohol, alter your diet to reduce sodium intake, and to avoid over the counter drugs and herbal supplements that may worsen your condition while strictly adhering to your medication regimen as prescribed by the physician. In addition to these measures, the nurse must recognize potential barriers that would prevent the client from following your education. Some examples include: confusion caused by conditions such as hepatic encephalopathy or other chronic liver disease, alcohol addiction can prevent clients from successfully treating their condition, and homelessness or a lack of support structure can interfere with clients maintaining their diet and general health. By recognizing these potential barriers, the nurse can tailor their client education to best support their recovery and reduce the chance of them being readmitted to the hospital.
When providing education to a client with cirrhosis, one of the most important things that needs to be emphasized is adherence to their medication schedule. When educating the client about adherence to medication such as lactulose, the client must understand that nonadherence can cause confusion and impaired decision making. So if the client makes a mistake when taking their medication, they may not realize that their condition is worsening. The most common cause of hospital readmission in patients with cirrhosis is Hepatic encephalopathy(Seraj 2017). Hepatic Encephalopathy occurs when the liver fails to remove toxins from the body and results in a loss of brain function. This can be prevented if the client adheres to their medication schedule. Lactulose for example is a laxative that reduces the amount of ammonia in the blood, which is necessary due to the impaired liver function caused by the cirrhosis. Also, the nurse must educate the client to not take any over the counter medication without first speaking to their physician, as many over the counter drugs can cause hepatotoxicity in patients with cirrhosis, such as acetaminophen. NSAIDS can also cause bleeding, which is bad because patients with cirrhosis tend to have low platelet counts, and are at higher risk for GI bleeds. For these reasons, education about medication adherence and avoidance of OTC drugs is important. The main barrier to this point of education is the impaired decision making that is caused by hepatic encephalopathy. Clients with severe cirrhosis may have a reduced baseline when it comes to decision making and memory, which will make their adherence to their medication more difficult. In addition, once their symptoms begin to worsen, they may fail to comply with their outpatient visits and as a result get even sicker until they have to be readmitted. Recognizing this barrier, the nurse may want to encourage/ educate the clients family or support group about signs of confusion and even teach them about the medication regimen, so that they may help the client keep up. Also, it may be important for the client to have resources available that can help them with transportation to the doctor or the pharmacy, as this will help them avoid nonadherence.
A common cause of cirrhosis is long term alcohol abuse, which is why the nurse must also educate the client with cirrhosis about avoidance of alcohol. This is simple, alcohol causes damage to the liver, and if the liver is already damaged (irreversibly) then the client must stop drinking alcohol immediately. The nurse can teach the client about treatment options such as rehabilitation clinics and support groups such as alcoholics anonymous. There are also medications that can help the client stop drinking such as antabuse, which will make the client sick when they try to drink. However, the addiction to alcohol can be a barrier to the client’s learning in that a severe alcoholic may not even consider quitting alcohol, or may relapse after treatment. If a client begins to drink alcohol again, then they may experience symptoms of hepatic encephalopathy and continue to make poor decisions in regards to OTC medication. For example, the client may take aspirin or tylenol by mistake for a headache while drunk, both of which will worsen their condition. To prevent this barrier from becoming a problem, the nurse must make sure the client understands the importance of quitting alcohol and takes steps to maintain sobriety.
The nurse must also teach their client about the importance of reducing sodium in the diet. The education should focus on the damage that salt can do to the liver, which is a problem for someone who already has severe liver damage. The nurse should help the client plan a diet and make sure the client demonstrates knowledge of which foods to avoid. A barrier to this point of education could be the clients socioeconomic status. Clients who are homeless are some of the most likely to be readmitted(Seraj 2017), and homeless clients may not have access to healthy, low sodium foods. The nurse must try to make sure the client knows how to adhere to the correct diet and has the resources to actually comply with the diet plan.
Bajaj, J. S., Reddy, K. R., Tandon, P., Wong, F., Kamath, P. S., Garcia-Tsao, G., Maliakkal, B., Biggins, S. W., Thuluvath, P. J., Fallon, M. B., Subramanian, R. M., Vargas, H., Thacker, L. R., O’Leary, J. G., North American Consortium for the Study of End-Stage Liver Disease (2016). The 3-month readmission rate remains unacceptably high in a large North American cohort of patients with cirrhosis. Hepatology (Baltimore, Md.), 64(1), 200-8.

Seraj, S. M., Campbell, E. J., Argyropoulos, S. K., Wegermann, K., Chung, R. T., & Richter, J. M. (2017). Hospital readmissions in decompensated cirrhotics: Factors pointing toward a prevention strategy. World journal of gastroenterology, 23(37), 6868-6876.