Table 1.
Summary of quality standards with level of agreement from the final round of the Delphi process
| Agreement | Responses | |
| People who are being asked about their alcohol use should have a validated alcohol questionnaire completed to identify any need for intervention. | 91% | 29% strongly agree 62% agree 6% disagree 2% strongly disagree |
|
94% | 55% strongly agree 39% agree 3% neutral 3% disagree |
| Assessment of hepatic fibrosis should be done using validated non-invasive liver fibrosis markers. | 100% | 78% strongly agree 22% agree |
| Patients identified at high risk of advanced fibrosis or cirrhosis should be offered referral for assessment by a gastroenterologist or hepatologist. | 97% | 74% strongly agree 24% agree 2% neutral |
| Patients presenting to hospital with liver disease should be screened for alcohol use disorder (AUD) and an estimation of typical no of units of alcohol per week recorded. | 76% | 38% strongly agree 44% agree 15% neutral 3% disagree |
| Patients admitted to hospital with ALD should be reviewed by a clinician trained in hepatology and the management of alcohol withdrawal within 24 hours of admission. | 88% | 49% strongly agree 39% agree 9% neutral 3% disagree |
| Patients admitted to hospital with ALD and AUD should be assessed by a specialist addiction practitioner during their admission and offered appropriate intervention and referral. | 97% | 68% strongly agree 29% agree 3% neutral |
| Alcohol withdrawal syndrome in patients with ALD with advanced liver disease, especially jaundice and/or encephalopathy, should be treated in a symptom-triggered fashion using a recognised symptom scoring system to avoid overuse of benzodiazepines. | 91% | 66% strongly agree 25% agree 9% neutral |
| It should be documented that patients have been advised that complete abstinence from alcohol is associated with better prognosis in ALD and that stopping alcohol entirely should be their goal. | 89% | 65% strongly agree 24% agree 12% neutral |
| Patients presenting with decompensated ALD or AH should be screened for infection. | 100% | 79% strongly agree 21% agree |
| All patients with decompensated ALD should have a nutritional assessment. | 100% | 85% strongly agree 15% agree |
| A plan for escalation of care in patients with ALD who develop acute-on-chronic liver failure (grades 2 or 3) should be clearly documented. | 100% | 78% strongly agree 22% agree |
| AH should be diagnosed in keeping with recognised clinical criteria, and patients suspected as having AH but who have confounding factors or do not fulfil all criteria should be considered for liver biopsy. | 93% | 59% strongly agree 35% agree 7% neutral |
| Patients with AH should have their prognosis assessed using a recognised prognostic scoring system (GAHS; MELD). | 100% | 77% strongly agree 23% agree |
| Corticosteroid treatment should be considered in patients with indicators of likely beneficial response (GAHS≥9; MELD 21–51; NLR 5–8) and without infection. | 85% | 58% strongly agree 27% agree 15% neutral |
| Response to treatment with corticosteroids should be assessed after 7 days and corticosteroid treatment discontinued if there is no response. | 86% | 45% strongly agree 41% agree 10% neutral 3% disagree |
| Patients should be provided with clear, written information about their liver disease in a manner that they can understand before they leave hospital. | 94% | 77% strongly agree 18% agree 6% neutral |
| The date and time of follow-up appointments should be arranged with patients before they leave hospital. | 88% | 56% strongly agree 32% agree 9% neutral 3% disagree |
| Patients hospitalised with decompensated ALD or AH should be followed up by clinicians with specialist interest in hepatology within 6 weeks of discharge. | 97% | 63% strongly agree 34% agree 3% neutral |
| Patients with ALD with AUD should be offered community-based alcohol support after discharge from hospital. | 94% | 77% strongly agree 18% agree 6% neutral |
| Access to addiction specialists should be available, when indicated, for all patients with decompensated ALD after leaving hospital. | 91% | 61% strongly agree 30% agree 9% neutral |
| Medicines to support abstinence are beneficial and should be continued in primary care after being started in hospital or in alcohol treatment. | 85% | 50% strongly agree 35% agree 15% neutral |
| Patients with ALD with ongoing hepatic failure and a UKELD score greater than 49 should be considered for liver transplant referral if they are abstinent from alcohol. | 87% | 47% strongly agree 40% agree 7% neutral 7% disagree |
| Patients with ALD with an expected survival of less than 12 months should have their condition discussed with palliative care services. | 91% | 73% strongly agree 18% agree 6% neutral 3% disagree |
AH, alcohol-related hepatitis; ALD, alcohol-related liver disease; GAHS, Glasgow Alcoholic Hepatitis Score; MELD, model for end-stage liver disease; UKELD, UK Model for End-Stage Liver Disease.