Table 3. Suggested quality indicators for management of liver cirrhosis³⁸ .

Ascites

Diagnostic paracentesis for new onset of moderate to severe ascites Diagnostic paracentesis for hospital inpatients and patients with hepatic encephalopathy No routine uses of fresh frozen plasma or platelet for paracentesis Requesting routine ascitic fluid tests; cell count and differential, total protein, albumin, and culture/sensitivity Salt restriction and diuretics* for moderate to severe ascites in patients with normal renal function ** Discontinuation of diuretics and fluid restriction in patients with ascites, if serum sodium less than 120 mEq/L Counseling for abstaining from alcohol consumption in all patients Prescribing empirical antibiotics within 6 hours, in hospitalized patients with PMN > 250 cells/mm3 in ascitic fluid ** Prescribing long term outpatient antibiotics in patients with first presentation of SBP, within 1 week of hospital discharge Prescription of antibiotics within 24 hours of admission for patients with variceal bleeding** Prophylactic antibiotics in patients with total protein < 1.1 g/dl in ascitic fluid and serum bilirubin > 2.5 mg/dl **

Variceal bleeding

Screening EGD for varices in compensated cirrhosis, within 12 months of diagnosis Screening EGD for varices in decompensated cirrhosis, within 3 months of diagnosis Not receiving NSBBs in patients with negative history of variceal bleeding, and no varices on EGD Receiving either NSBBs or EVL in patients with negative history of variceal bleeding, and medium/large varices on EGD** Repeating EGD 1 year after the index EGD in decompensated cirrhosis, with small varices, not on NSBBs Doing tests: CBC, BUN, creatinine, blood type, and cross-match at initial evaluation if acute Variceal bleeding Considering at least 1 large-bore intravenous line at the time of initial evaluation if presented with acute UGIB Documentation of resting and orthostatic vital signs at initial evaluation in patients with acute UGIB Considering crystalloid fluids at the time of initial evaluation in patients with acute UGIB with signs of hypovolemia Considering ICU care for patients with active bleeding or hypovolemia who are not responsive to initial fluid resuscitation Starting somatostatin or its analogues in patients with cirrhosis and acute GIB within 12 hours of presentation ** Performing EGD within 24 hours of presentation in patients with UGIB ** Documenting the location, stigmata of bleeding, and control of bleeding in EGD procedure note Performing EVL or sclerotherapy in patients with bleeding of esophageal varices, in the index EGD ** Receiving repeated EGD with EVL or TIPS in patients with repeated UGIB within 72 hours of index EGD Preventing the recurrence of bleeding with EVL every 1–2 weeks until obliteration, beta-blockers, or a combination of both **

Hepatic encephalopathy (HE)

Documenting the grade of HE in the chart Documenting the search for reversible factors of HE in the chart Counseling the risks associated with driving in patients with HE Receiving oral disaccharides or rifaximin in patients with persistent HE**

Liver transplantation indications

Considering liver transplantation if MELD score is > 15 and there is no absolute contraindications for LT Considering LT if MELD score is < 15, only when there is no absolute contraindication for LT and one of the following conditions exist; refractory ascites, recurrent variceal bleeding, recurrent HE, SBP, hepatopulmonary syndrome, or HCC meeting Milan’s criteria

Preventive (general) care

HAV vaccination in non-immune patients HBV vaccination in non-immune patients Documentation of the MELD score in decompensated cirrhosis in initial evaluation

* spironolactone + a loop diuretic with salt restriction to about 2000 mg sodium chloride per day, **: most important with highest levels of evidences, SBP: Spontaneous bacterial peritonitis, HE; Hepatic encephalopathy, EGD: Esophagogastroduodenoscopy, NSBBs: Non-selective beta blockers, signs of hypovolemia: pulse rate > 100 per minute, systolic blood pressure < 100 mm Hg; or orthostatic changes, UGIB: Upper gastrointestinal bleeding, EVL: Endoscopic variceal ligation, TIPS: Transjugular intrahepatic portosystemic shunt, MELD: Model for end stage liver disease, LT: Liver transplantation, HAV: Hepatitis A virus, HBV: Hepatitis B virus