Recommendations
Urgent
Manage sepsis and organ failure, if present. Investigate for the cause of sepsis with a view to source control.
In patients with organ dysfunction, transfer the patient to the intensive care unit to monitor and treat the organ dysfunction.
Provide fluid resuscitation, along with analgesia and antibiotics (if infection is suspected), prior to surgery.[27][34][52]
Arrange urgent surgery for patients with generalised peritonitis or emphysematous cholecystitis.[3]
Key Recommendations
Initial treatment
In all patients, give analgesia, fluid resuscitation, and antibiotics (if infection is suspected), as required.[27][34][52]
Assess severity and identify sepsis.
Assess fluid status and resuscitate with intravenous fluids as appropriate.
Monitor the patient using an early warning score, such as the National Early Warning Score 2 (NEWS2) score.[28]
Prior to surgery, identify and treat any correctable comorbidities so that surgery is not delayed and assess the patient’s bleeding and venous thromboembolism risk.[55]
Surgery
Refer for a laparoscopic cholecystectomy.
The UK National Institute for Health and Care Excellence (NICE) states that surgery should be performed within a week of diagnosis where resources allow.[4]
Other sources state that surgery within 72 hours of onset is preferable.[27][52]
If a surgeon with experience of operating on patients with acute cholecystitis is not available locally, consider transferring the patient to a specialist unit.[27]
Refer for a percutaneous cholecystostomy patients who are unfit for general anaesthesia and surgery, who do not improve after treatment with antibiotics, analgesia, and fluid resuscitation.[27]
Gallbladder drainage is not a permanent solution, and where possible a delayed cholecystectomy (>6 weeks after drainage) is recommended.[56]
Endoscopic ultrasound-guided gallbladder drainage can also be considered when surgery is not an option - this is a technically challenging procedure and should only be done in specialist centres.[57] It is important to note that it is not a permanent solution but rather a bridge to surgery, and assessment for future cholecystectomy should resume once the acute episode and any underlying sepsis has been treated.[56]
Complications
Offer percutaneous cholecystostomy to manage gallbladder empyema when surgery is contraindicated at presentation and conservative management is unsuccessful.[4]
Consider urgent laparoscopic cholecystectomy in patients at high risk of gangrene.[3]
Perforation occurs in 10% of cases of acute cholecystitis.[3]
Consider percutaneous drainage of the resulting collection or expedited surgery. Treatment should be tailored to the individual circumstances of each patient.
The main treatment goals are to:
Manage sepsis, if suspected
Provide supportive treatment to reduce the risk of progression to organ failure and/or local complications
Treat the underlying cause
Manage local complications.
Treat patients with acute cholecystitis in hospital.[27]
Transfer patients to a specialist unit with surgeons experienced at performing surgery on this group of patients if such surgeons are not available locally.[27]
Patients with severe (Tokyo guideline grade III) cholecystitis should be managed in an intensive care setting.[52] See Assessing severity in Diagnosis recommendations for guidance on how to define grade of cholecystitis.
In all patients, give analgesia, fluid resuscitation, and antibiotics (if infection is suspected), as required.[27][34][52] Most patients will require surgery. Patients should be nil by mouth in order to rest the gallbladder and because of the likelihood of imminent surgery.[3][52]
In patients with severe acute cholecystitis (grade III according to the Tokyo guideline; see Assessing severity in Diagnosis recommendations for guidance on how to define grade of cholecystitis):[52]
Transfer the patient to the intensive care unit to monitor and treat the organ dysfunction
Determine the degree of organ dysfunction and attempt to normalise function through organ support
Consider urgent/early biliary drainage if it is not possible to control the gallbladder inflammation.
Analgesia
Pain is the predominant symptom. Ensure it is treated promptly and effectively.[52]
Failure to control pain can compromise breathing and contribute to haemodynamic instability.
Use a pain score to monitor the response to analgesia and adjust the dose and/or type of analgesic medication in line with local pain management protocols.
Use paracetamol or a non-steroidal anti-inflammatory drug such as diclofenac or indometacin initially.[27][58] Move onto opioid analgesia (e.g., morphine) if required.[10]
Fluid resuscitation
Assess fluid status and resuscitate with intravenous fluids as appropriate.
Administer intravenous fluids, if needed, to all patients who cannot tolerate oral intake
Give intravenous fluids based on fluid status assessment.[59]
Use either a balanced crystalloid or normal saline 0.9% initially.
Check local protocols for specific recommendations on fluid choice. There is debate, based on conflicting evidence, on whether there is a benefit in using normal saline or balanced crystalloid in critically ill patients.
Tailor the intravenous fluid to the patient’s condition and electrolytes.
Regularly monitor patients receiving intravenous fluids.[59]
Clinical monitoring should include current status and trends in:
National Early Warning Score (NEWS2)
Fluid balance charts
Weight.
Laboratory investigations should include current status and trends in:
Full blood count
Urea
Creatinine
Electrolytes.
Treat the underlying cause as early as possible. Consider local protocols but, in general, escalate patients with shock to a senior clinician. See our topic Shock.
Practical tip
Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloraemic acidosis.
Also note that use of lactate-containing fluid in a patient with impaired liver metabolism may lead to a spuriously elevated lactate level, so results need to be interpreted with other markers of volume status.
Evidence: Choice of fluids
Evidence from two large randomised controlled trials (RCTs) suggests there is no difference between normal saline and a balanced crystalloid for critically ill patients in mortality at 90 days, although results from two meta-analyses including these RCTs point to a possible small benefit of balanced solutions compared with normal saline.
There has been extensive debate over the choice between normal saline (an unbalanced crystalloid) versus a balanced crystalloid (such as Hartmann’s solution [also known as Ringer’s lactate], or Plasma-Lyte). Clinical practice varies widely, so you should check local protocols.
In 2021 to 2022 two large double blind RCTs were published assessing intravenous fluid resuscitation in ICU patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline. The Plasma-Lyte 148 versus Saline (PLUS) trial (53 intensive care units [ICUs] in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[60][61]
In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis or post-surgery. They also found no difference in the risk of AKI.
In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90 day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[62]
A subsequent individual patient data meta-analysis included 6 RCTs of which only PLUS and BaSICS were assessed as being at low risk of bias. There was no statistically significant difference in in-hospital mortality (OR 0·96, 95%CI 0·91–1·02). However, the authors argued that using a Bayesian analysis there was a high probability that balanced solutions reduced in-hospital mortality, although they acknowledged that the absolute risk reduction was small.[63]
A prespecified subgroup analysis of patients with traumatic brain injury (N=1961) found that balanced solutions increased the risk of in-hospital mortality compared with normal saline (OR 1·42, 95%CI 1·10 to 1·82).
Previous evidence has been mixed.
One 2015 double-blind, cluster randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[64]
However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs 11.1%; OR 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[65]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[66]
The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high quality evidence as assessed by GRADE), acute renal injury (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).
Antibiotics
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[32][42]
For patients with suspected biliary infection, start antibiotics as soon as infection is suspected and before any procedure is performed.[67] Not all patients will require antibiotics; do not start antimicrobial therapy unless there is clear evidence of an infection.[68]
Follow local policy and consider discussing with microbiology/infectious disease colleagues to determine the most appropriate choice. Avoid inappropriate use of broad-spectrum antibiotics.[68]
Consider antimicrobial stewardship, such as the ‘start smart – then focus’ principles from Public Health England.[68]
Ask about any antibiotic use in the last 6 months. The patient is more likely to be harbouring a resistant organism if they have a recent (within 6 months) history of antibiotic use.[67]
Take a thorough drug allergy history when prescribing antibiotics.[67][68]
Expert opinion suggests that empirical intravenous therapy should be chosen bearing in mind the following factors:[67]
Observational studies have demonstrated that Escherichia coli is the organism most frequently implicated
Local susceptibility patterns vary geographically and over time
The likelihood of resistance of the organism will also vary by whether the infection was hospital- or community-acquired, although there may be resistant organisms in the community
More-severe grades of infection require more potent antibiotics (monotherapy or combination therapy).
Use a definitive therapy once the sensitivities are reported from culture specimens.[67]
Specific therapy may involve penicillins, cephalosporins, or fluoroquinolones.[67]
Change intravenous therapy to oral antibiotics when the patient is able to eat. Stop the antibiotics when safe to do so.[67][68]
The duration of therapy needs to balance benefits (eliminating the infection and reducing the risk of complications) against risks (resistant organisms, the cost of therapy, and the prolonged length of hospital stay).[67]
The majority of patients should be offered cholecystectomy. Only patients who are not fit for surgery, or who have localised complications that would make surgery dangerous, should be managed conservatively (with the option of a delayed cholecystectomy). These decisions will be made by a specialist.
Presurgical assessment
Prior to surgery, identify and treat any correctable comorbidities so that surgery is not delayed.
Assess the patient’s bleeding and venous thromboembolism risk prior to surgery.[55]
Use a validated tool. The UK National Institute for Health and Care Excellence (NICE) states that a commonly used risk assessment tool for surgical patients is the Department of Health venous thromboembolism risk assessment tool.[55]
Arrange a group and save and crossmatch.
Reassess the risk of bleeding and venous thromboembolism at the point of consultant review or if the patient’s clinical condition changes.
Use a risk score, such as the American Society of Anesthesiologists (ASA) physical status classification system to stratify a patient's health status before surgery.[52][69]
Laparoscopic cholecystectomy
Refer for a laparoscopic cholecystectomy under general anaesthesia in patients fit for surgery.[4]
NICE states that surgery should be performed within a week of diagnosis where resources allow.[4]
Other sources state that surgery within 72 hours of onset is preferable.[27][52]
In patients with severe cholecystitis, manage organ dysfunction in an intensive care unit prior to surgery.
If a surgeon with experience of operating on patients with acute cholecystitis is not available locally, transfer the patient to a specialist unit.[27]
Severe inflammation of the gallbladder and its surroundings increases the difficulty of a laparoscopic cholecystectomy and the frequency of postoperative complications.[70]
The following risk factors are associated with prolonged operative time:[70]
Gallbladder wall thickening
Incarcerated stones in the gallbladder neck
Duration of elevated C-reactive protein
Non-visualised gallbladder on preoperative cholangiography
Body temperature
Abscess formation
BMI.
The following risk factors are associated with conversion to open procedure:[70]
Gallbladder wall >4 to 5 mm on preoperative ultrasound
Age >60 or 65 years
Male Acute cholecystitis (Tokyo guidelines grade II/III)
Contracted gallbladder on ultrasound
Previous abdominal surgery
BMI
ASA score.
Evidence: Efficacy of laparoscopic cholecystectomy
The NICE interventional procedures guidance on single-incision laparoscopic cholecystectomy (SILC) found that studies comparing SILC with conventional multiport laparoscopic cholecystectomy (CMLC) efficacy had mixed results depending on outcomes measured.[71]
In terms of efficacy, the NICE interventional procedures guidance included two systematic reviews.
One systematic review included 25 randomised controlled trials (RCTs) involving a total of 1841 patients comparing SILC with CMLC.[72]
A meta-analysis of these data found significant differences between the groups on six efficacy measures: two favouring CMLC (operative time and the need for additional instrumentation) and four favouring SILC (the length of the incision, pain at 3-4 hours, pain at 6-8 hours, and cosmesis score).
There was no significant difference in the meta-analysis on conversion to open surgery, blood loss, time to oral intake, length of stay, time to return to work, or pain at 12 or 24 hours.
Three of the RCTs in this review reported quality of life: in one, this was worse at 1 month for the SILC group than for the CMLC group (mean 51.1 vs. 54.1 on the short-form 12 [SF-12] scale, P = 0.03); in one it was better at 1 month for the SILC group (median 40 vs. 35 on the SF-12, P = 0.028); and in the third there was no significant difference between the groups at 10 days (mean 101.6 vs. 102.5 on the gastrointestinal quality-of-life index, P = 0.567).[73][74][75]
The other systematic review included 40 studies (16 RCTs and 24 non-randomised comparative studies) involving a total of 3711 patients, with some overlap of the studies included in this review and the one above.[76]
Meta-analysis of these data showed significant differences between the groups on five efficacy measures: two favouring CMLC (conversions and operative time) and three favouring SILC (length of incision, length of stay, and cosmesis score at 1 month).
There was no significant difference in terms of blood loss; analgesia use; time to return to work; pain at 24 hours, 48 hours, 72 hours, or 1 week; or cosmesis score at 3 or 6 months).
Evidence: Safety of laparoscopic cholecystectomy
NICE concludes that current evidence on the safety and efficacy of single‑incision laparoscopic cholecystectomy (SILC) is adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent, and audit.
In terms of safety, the NICE interventional procedures guidance included two systematic reviews, a non-systematic review of safety data, and expert opinion.[71]
One systematic review included 25 randomised controlled trials (RCTs) involving a total of 1841 patients.[72]
A meta-analysis of these data found no significant difference in bile-duct injuries (odds ratio [OR] 1.00, 95% CI 0.165 to 6.066, P = 1.0), retained gallstones (OR 2.15, 95% CI 0.55 to 8.33, P = 0.269), or incisional hernia (OR 1.937; 95% CI 0.658 to 5.706, P = 0.230).
One of the studies reported the rate of gallbladder perforation was 9/75 (12%) with SILC versus 6/75 (8%) with conventional multiport laparoscopic cholecystectomy (no P value reported).[74]
Another study reported similar rates of erythema (5/119 [4%] vs. 0/81 [0%]) and ecchymosis (1/119 [1%] vs. 0/81 [0%]).[73]
The other systematic review included 40 studies (16 RCTs and 24 non-randomised comparative studies) involving a total of 3711 patients.[76]
Meta-analysis of these data showed no significant difference between the groups for wound haematomas (OR 2.07, 95% CI 0.90 to 4.74, P = 0.09), wound infections (OR 1.03, 95% CI 0.53 to 2.0, P = 0.92), or incisional hernias (OR 1.67, 95% CI 0.65 to 4.27, P = 0.29).
A non-systematic review of adverse events after SILC (with no comparator) included 38 studies involving a total of 1180 patients, of whom 17 (1%) reported seroma, 2 (0.17%) had ileus, and 1 (0.08%) had renal failure.[77]
Experts suggest that other theoretical adverse events (which are not known to have been reported in the literature) include retained gallstones, incisional hernias, or injuries to the viscera.[71]
Evidence: Timing of cholecystectomy
Benefits and complications vary according to when surgery is performed.
A meta‐analysis including 15 randomised controlled trials found that early cholecystectomy (defined as either within 1 week or within 72 hours) was similar to delayed cholecystectomy in terms of mortality and complication rates.[52]
There was no difference in length of hospital stay after surgery, but total hospital stays were shorter for early cholecystectomy.
Overall cost of treatment was lower with cholecystectomy performed within 72 hours compared with delayed surgery.
There was no difference in the incidence of bile duct injury, but authors reported that the total number of patients was too small to draw conclusions regarding this complication.[52]
Another meta-analysis including 15 randomised controlled trials compared early laparoscopic cholecystectomy (defined as within 7, 4, or 3 days) with delayed laparoscopic cholecystectomy.[78]
There was no difference in bile duct injury and bile leakage, rate of wound infection, total complications, conversion to open surgery, or operation times, but early laparoscopic cholecystectomy performed within 7 days was associated with a longer surgery time.
Early laparoscopic cholecystectomy was found to significantly shorten the duration of total hospital stay.
A comparison of surgery performed within 24 hours of symptom onset and surgery performed within 72 hours showed that the outcomes from the 24-hours group were not superior to those in the latter group.[79]
A systematic review for the 2014 NICE guideline on gallstone disease found six randomised controlled trials comparing early laparoscopic cholecystectomy (within 1 week of the acute presentation) with delayed laparoscopic cholecystectomy (more than 4 weeks after presentation) for people with acute cholecystitis.[4]
Readmission rates and length of stay were lower with early versus delayed laparoscopic cholecystectomy and quality-of-life scores were higher.
Early laparoscopic cholecystectomy was more cost-effective compared with delayed laparoscopic cholecystectomy.
Percutaneous cholecystostomy
Refer for a percutaneous cholecystostomy patients who are unfit for general anaesthesia and surgery, who do not improve after treatment with antibiotics, analgesia, and fluid resuscitation.[27]
The aim is to drain fluid from the infected gallbladder in patients at high surgical risk.[4]
The procedure involves inserting a drainage catheter in the gallbladder through a small entry hole made in the abdominal wall.[57]
This procedure could relieve the symptoms completely, or at least allow the patient’s condition to improve sufficiently for a definitive elective procedure (laparoscopic cholecystectomy) to be undertaken later, rather than in an emergency situation.[4]
An incomplete or poor response to cholecystostomy within the first 48 hours may indicate causes of sepsis other than cholecystitis, inadequate antibiotic coverage, possible complications (such as dislodgement of the drainage tube), or necrosis of the wall of the gallbladder.[3]
Offer percutaneous cholecystostomy to manage gallbladder empyema when surgery is contraindicated at presentation and conservative management is unsuccessful.[4]
Evidence: Percutaneous cholecystostomy
Evidence is limited on the balance of risks and benefits of percutaneous cholecystostomy.[80]
NICE guidelines suggest percutaneous cholecystostomy in patients in whom it is safer to avoid a general anaesthetic but the infection is not resolving with conservative measures (fluids and antibiotics).[4]
Two small trials included in a Cochrane systematic review suggest that percutaneous cholecystostomy and early laparoscopic cholecystectomy may reduce length of hospital stay and costs, but the evidence base is not robust.[80]
The review found two randomised controlled trials (both at high risk of bias) involving a total of 156 participants.[80]
One trial involving 70 participants compared percutaneous cholecystostomy (within 8 hours of referral to the surgeon) followed by early laparoscopic cholecystectomy (within 96 hours when patient improved) versus delayed laparoscopic cholecystectomy (8 weeks after the symptoms settled).[81]
It found a shorter length of stay (mean difference -9.90 days, 95% CI -12.31 to -7.49) and lower costs (mean difference -1123 US dollars, 95% CI -1336.60 to -909.40 US dollars) with percutaneous cholecystostomy followed by early laparoscopic cholecystectomy. There was no significant difference between the groups in terms of the numbers of participants needing conversion to open cholecystectomy, complications, or mortality.[81]
The other trial involving 86 participants compared percutaneous cholecystostomy (within 24 hours of referral) versus conservative treatment; either could be followed if necessary by delayed cholecystectomy (not stated how many were laparoscopic or converted to open operations).[82]
It found no significant difference between the groups on the numbers needing delayed laparoscopic cholecystectomy.[82]
Endoscopic ultrasound-guided gallbladder drainage
An alternative option for patients with acute cholecystitis where surgery is not an option is endoscopic ultrasound-guided gallbladder drainage.[57]
In patients where surgery is unsuitable (either due to the risks involved or the presence of other conditions which may make surgery unsuitable) NICE recommends that endoscopic ultrasound (EUS) guided gallbladder drainage can be used as an alternative.[57]
The procedure is typically carried out under sedation or general anaesthesia using a specialist endoscope, with an ultrasound probe and fluoroscopic guidance, to insert a stent through an anastomotic tract created into the gallbladder through the wall of the stomach or duodenum.
There is good evidence to show that this procedure is effective in treating acute cholecystitis and the aim is to drain bile from the gallbladder to avoid the need for emergency cholecystectomy, though it is a technically challenging procedure which should only be done in specialist centres by clinicians trained and experienced in using this procedure for gallbladder drainage.[57][83][84][85][86]
A disadvantage of the procedure when compared to cholecystectomy is that cholecystitis may reoccur.[57]
It is important to note that it is not a permanent solution but rather a bridge to surgery, and assessment for future cholecystectomy should resume once sepsis has been treated.[56]
Gallbladder empyema
Offer percutaneous cholecystostomy to manage gallbladder empyema when surgery is contraindicated at presentation and conservative management is unsuccessful.[4]
Gallbladder empyema can result when cholecystitis is left to progress with concurrent bile stasis and cystic duct obstruction.
It is a surgical emergency.
Gallbladder empyema is the most severe form of acute cholecystitis.
Reconsider laparoscopic cholecystectomy for people who have had percutaneous cholecystostomy once they are well enough for surgery.[4]
Gangrenous cholecystitis
Consider urgent laparoscopic cholecystectomy in patients at high risk of gangrene.[3]
Gangrene occurs most commonly at the fundus due to a compromised vascular supply.[3]
Have a low threshold for conversion to open cholecystectomy during the procedure.[3]
Gallbladder perforation
Perforation may require percutaneous drainage of the resulting collection or expedited surgery. Treatment should be tailored to the individual circumstances of each patient.[3]
Perforation occurs in 10% of people with acute cholecystitis.[3]
This is often when there has been a delay in seeking or receiving medical attention or in patients who do not respond to conservative management.[3]
Perforation most commonly occurs at the fundus.[3]
After the gallbladder has perforated, patients may experience transient relief of their symptoms because the gallbladder decompresses, but peritonitis then develops.[3]
Acute cholangitis
Mortality risk is high. Treat with antibiotic therapy and reduce the biliary pressure.[87]
Acute cholangitis occurs when biliary stenosis results in cholestasis and biliary infection.[87]
The stenosis or blockage may be due to benign causes, such as bile duct stone, or a tumour.
This elevates pressure within the biliary system and flushes the micro-organisms or endotoxins from the infected bile into systemic circulation, which causes a systemic inflammatory response.
See our topic Ascending cholangitis for more information.
Provide simple analgesia, such as paracetamol or a non-steroidal anti-inflammatory drug, for postoperative pain; it is usually minimal.
Advise patients that they do not need to avoid any particular food or drinks after having their gallbladder or gallstones removed, but to seek further advice from their general practitioner if eating or drinking causes new symptoms to develop.[4]
Ask about any nausea, vomiting, and abdominal pain. Review the wound for erythema, discharge, or pain.
In a survey of patients followed up by a weekly telephone questionnaire for 6 weeks after laparoscopic cholecystectomy, 22% reported nausea and vomiting continuing after hospital discharge, 11% said postoperative pain was not controlled by prescribed analgesia after hospital discharge, and 70% reported wound-related symptoms such as discharge.[88]
Continue to assess for signs of jaundice.
Liaise with community colleagues to offer a care package post discharge.
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