HPB P22 Improving Time to ERCP for Acute Gallstone Cholangitis Admissions at a District General Hospital: A Closed Loop Audit

Abstract

Abstract Background The National Institute of Health and Care Excellence (NICE) guidelines recommend that adults with acute gallstone cholangitis receive endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours of diagnosis, especially in the moderate-severe cases. Early intervention is associated with improved patient outcomes. For smaller district general hospitals with limited resources, achieving these targets can be difficult. We audited our management of patients admitted with obstructive gallstone disease (cholangitis and pancreatitis) with aim of improving timely access to ERCP. Methods We performed a closed loop audit investigating time to ERCP in patients admitted with acute gallstone cholangitis at a UK district general hospital. Severity was graded according to the 2018 Tokyo Guidelines. Data was collected over a 5-month period (01/05/2023 to 01/10/2023), analysed and presented to the surgical multi-disciplinary team. Additional referral pathways to 3 nearby tertiary care centre for ERCP were established. Post-intervention admissions were re-audited over a second 5-month period (01/01/2023 to 01/06/2023) to assess the effect of the new referral pathways. Results Forty-one patients received ERCP for acute gallstone cholangitis (14 mild cases; 17 moderate; 10 severe). Pre-intervention, overall median time to ERCP was 10 days (5–24). For moderate-severe and mild cases median times to ERCP were 8 (5–19) and 28 days (9–46), respectively. The new referral pathways reduced overall median time to ERCP to 6 days (4–9). For moderate-severe and mild cases, post-intervention median times to ERCP were 6 days (6–8) and 4 days (4–25), respectively. Median length of stay pre- and post-intervention was 8 (6–13) and 7 days (4–10), respectively. Conclusions The management of acute gallstone cholangitis poses a significant burden on district general hospitals, particularly those with limited resources. By establishing additional referral pathways to nearby tertiary care centres, we successfully reduced median time to ERCP for local patients with moderate-severe acute gallstone cholangitis. This change may have may have also contributed to a reduction in overall length of stay and shorter waiting times for ERCP in mild cases of gallstone cholangitis. These findings underscore the importance of collaborative efforts between district general hospitals and tertiary centres to enhance patient outcomes.