WELCOME TO THE BRITISH ASSOCIATION FOR THE STUDY OF THE LIVER

NHS Jobs advert: https://www.jobs.nhs.uk/xi/vacancy/916009530 

This is for a Clinical Research Fellow in Hepatology to be supervised by Dr Richard Aspinall in Portsmouth. The post is for an initial 12 months with the expectation to extend to 2 or 3 years.

In addition to helping deliver NIHR portfolio studies, the research fellow will be supported to develop an investigator led project subject to their interests and register for a higher degree. Potential projects are negotiable but existing opportunities include projects in alcohol related illness, NAFLD/NASH, portal hypertension, renal dysfunction in cirrhosis and ongoing collaborations with public health colleagues.

Informal enquiries are welcomed. Please contact Dr Richard Aspinall, NIHR Wessex Research Network Lead for Hepatology by email richard.aspinall@porthosp.nhs.uk or telephone 02392 28 6255. 

Closing date 30th April 2020.

Important update from the BSG VP Hepatology and the BASL and BSG Presidents

During the COVID-19 outbreak the NHS is doing everything it can to keep patients with liver disease safe. However, risks relate not just to the infection itself, but also to the significant disruption of routine care due to the pandemic. Information from China and Italy suggest that hospital admissions for non-COVID-19 illness can lead to further spread of infection. Changes in routine care are now required to keep vulnerable patients with liver disease out of hospital as much as possible. However, changes to the way care is delivered for patients with liver disease must be balanced against the risks of undertreating them.

‘Social distancing’ and ‘self-isolation’ are measures to reduce spread within a population and to protect high risk groups. The impact of immunosuppression on the severity of COVID-19 disease remains unclear. Factors associated with more severe disease are older age and presence of other medical conditions. These are also an understandable source of anxiety for patients with liver disease. Government guidance in this area is dynamic and all people in the UK should follow up to date recommendations from the government.

The government recommends social distancing for all in the UK, but this guidance defines a ‘high-risk’ group of patients with liver disease who are advised to take additional measures and go into self-isolation for 12 weeks.

Patients with liver disease in high risk group*:

`Shielded group` Advise mandatory self – isolation:

1) Patients having undergone liver transplantation and taking immunosuppression and

2) Patients with autoimmune hepatitis taking immunosuppression

The consensus view in our specialty acknowledges the higher risk for patients with decompensated cirrhosis, who are not included in the shielding cohort. We recommend that these patients with decompensated cirrhosis should be advised to adhere strictly to social distancing measures in order to protect themselves. Clinicians will not, however, have to identify this group to their GPs for coding as COVID at RISK.

*There may be others not in the above groups felt by the treating physician to also be at higher risk and these should be assessed on a case-case basis.

General Principles

• All healthcare professionals have a responsibility to safeguard patients, colleagues and themselves from the COVID 19 virus.
• We wish to emphasise the importance of following current guidance and advice from Public Health England, Health Protection Scotland, Public Health Wales and Public Health Agency Northern Ireland.
• You will find any updates to this document on the BSG website.

Potential Impact on Gastroenterology and Hepatology Services

• Based on developments over the last few days, it is likely that the NHS will have to manage increasing numbers of patients with COVID 19. There is a shared understanding that if COVID 19 becomes a significant epidemic in the UK, clinical services will be stretched and that this will be exacerbated by staff shortages due to sickness, imposed isolation and caring responsibilities.
• It is likely that there will be increasing requirements for healthcare professionals in gastroenterology and hepatology to support NHS Healthcare providers in managing the care of acutely ill patients. This will likely result in disruption or cancellation of clinics and endoscopy lists and other specialist activities.

Redeployment of Staff to Managing Acutely Unwell Patients

• In the event of a significant outbreak, healthcare professionals in gastroenterology and hepatology will be asked to support broader patient and population needs.
• It is important that these activities are considered in the context of patient safety. Healthcare professionals should not undertake any activity beyond their level of competence.
• Healthcare professionals should avail themselves of training opportunities to equip them to undertake specific tasks in looking after acutely unwell patients either with suspected or confirmed COVID 19 infection.

Advice for patients with Inflammatory Bowel Disease on immunosuppression

• The following advice is from Public Health England and is well summarised by Crohn’s and Colitis UK and the International Organisation for IBD (IOIBD).
• People taking immunosuppressants for their Crohn’s Disease or Ulcerative Colitis are not at increased risk of catching novel coronavirus, however they may be at extra risk of complications from the virus if they are infected.
• People on immunosuppressants should seek advice by telephone if they develop symptoms of either seasonal Influenza or novel coronavirus.
• For the majority of patients, it is advisable to continue with immunosuppressive treatment and other treatments for their inflammatory bowel disease.
• Patients are advised to take precautions to avoid infection through good personal hygiene and avoiding unnecessary close contact with people who are unwell.
• If patients stop taking immunosuppressive medicine, they may have a flare which will increase the risk of complications if infected with coronavirus.
• If patients still have concerns about continuing the medication, they should speak to the medical team.
• If patients are at an increased risk of infection, for example, if they have been in direct contact with an infected individual, have travelled to a high infectivity area, or have another serious comorbidity that increases the risk further, they should seek advice from their medical team by telephone before making any changes to their medication.

Telephone and Virtual Clinics

• In order to maintain social distancing and reduce the risk of transmission of COVID-19, we encourage telephone consultations with patients or virtual clinics to avoid patients having to attend the clinic in person.
• We suggest that in such circumstances, a clause is added to the clinics letter that the patient has not been examined and that part of the assessment is therefore limited but has been only omitted due to exceptional circumstances.
• Good IT support is necessary to support telephone or virtual clinics, for example use of Skype.

Hepatology Patients

• Acute services can be helped by reducing acute admissions where possible by setting up alternative routes of care as in the case of day-case unit paracenteses services to prevent emergency admissions for paracentesis (these can be about 100/100,000 population).
• Patients suitable for telephone and virtual clinics include those with stable cirrhosis and those long-term after transplant.
• Patients post-transplant, those with AIH on second line immunosuppression, and those with decompensated cirrhosis and/or alcoholic hepatitis patients are considered high risk for COVID 19.
• Patients with compensated cirrhosis are considered to be in the intermediate risk group for COVID 19.

Advice for Patients with Liver, or Small Bowel Transplants

• We recommend that healthcare professionals looking after such patients refer to the guidance from the British Transplantation Society.

Endoscopy and COVID19

• Endoscopy Teams are advised to follow both national guidance for reducing transmission of infection with COVID19 (websites above) but also agree their own local protocols and policies in collaboration with senior management, Infectious Disease or Infection Control teams. There are both general measure that should be followed and specific measures around personal protective equipment (PPE).
• General measures include checking patient’s travel history at admission, providing a COVID19 information sheet about symptoms to report and checking patients temperatures upon arrival. Where there is concern, elective procedures should be postponed and rebooked as soon as possible once the patient no longer poses a risk. Units should develop standard operating procedures (SOP) for COVID19 control measures and share these widely among staff groups.
• PPE for endoscopy procedures – advice is that standard infection control measures should be followed except for aerosol generating procedures (AGP) in patients at high risk of or with confirmed COVID19 infection. AGP in this context means upper GI procedures and for patients who fall into this category, enhanced PPE is recommended including FFP3 masks. Endoscopy teams should also consider enhanced PPE for emergency and out-of-hours procedures and also consider arrangements for the most appropriate location to perform these within their hospital. Units are encouraged to ensure staff know how to be fitted for the appropriate size of FFP3 mask and how to put on PPE correctly.
• Official advice is that enhanced PPE is not currently felt to be necessary for upper endoscopy in patients at low risk or for lower GI procedures. Concerns have been raised that the virus may be faecally transmitted but there is presently insufficient evidence to recommend the use of enhanced PPE measures for lower GI procedures. Stocks of FFP3 masks are also limited and their use needs to be carefully prioritised. This is, however, a rapidly changing situation and teams should check regularly for updates to both local and national guidance
• Units should discuss locally and consider whether or not to suspend some endoscopic activity e.g. low-risk surveillance scopes (non-dysplastic Barrett’s, polyp follow-up, IBD etc) for a period to help reduce or delay virus spread but also as it is likely there will be staff shortages through illness, absence to care for others or redeployment.

Summary

Individual hospital trusts and health boards will be looking to implement local guidance based on national and international best practice. For reasons mentioned above, we encourage telephone or virtual clinics. This guidance aligns with the current data available but as the situation changes further guidance may be required. Individual treatment decisions about patient care will be between the patient and the treating physician.

Dr Tony Tham
Clinical Services & Standards Committee Chair
BSG