Acute Upper GI

Bleeding – how we

got where we are?

Dr Ian Forgacs

29 January 2014

Gut 2013 62: 242-249

UK IBD Audit

National clinical audits

Clinical registries

Clinical databases

National survey Research database

Audit database

Surveillance system

Network Data repository

Audit system

Clinical administration system

National clinical databases

IBD Standards

• Launched between Feb and April 2009

• Copies sent to trust and Board CEOs with the 2nd round IBD Audit results

• Circulated to SHAs, Primary Care Trusts, Local Health Boards

• Work to establish a political lobby

The UK comparative audit of acute upper gastrointestinal

bleeding

British Society of

Gastroenterology

Why? Rockall 1993/4

Mortality 14% overall

33% in inpatients; 11% in emergency admissions

Endoscopy use variable

What has changed ?

Early identification of high risk patients

Therapeutic endoscopy

Drug use in AUGIB

And...

Blood transfusion in AUGIB – never audited

What were they looking for?

Changes in mortality

Is the Rockall score still useful

Impact of therapeutic endoscopy

Use and effect of blood transfusion

Is there a relationship between

service provision and outcome?

257 UK hospitals invited

217 hospitals (84%)

8939 cases submitted

1090 insufficient data

1099 not UGIB

6750 analysed (76%)

Prospective study

Web-based data entry

Mortality 10% overall

7% in those who had endoscopy

45% of deaths were in patients who did not have endoscopy

Rockall

score

Expected

deaths

(1993/4 risk)

Observed

deaths

2007

Relative risk

(95% CI)

0-2 (1408) 2 13 7.6 (3.49 to 5.85)

3-5 (2204) 143 125 0.9 (0.73 to 1.05)

6-7 (942) 201 122 0.6 (0.55 to 0.78)

≥8 (435) 179 110 0.6 (0.50 to 0.74)

44% of hospitals do not have formal out of hours rota for endoscopy

60% of patients present out of hours

19% of new admissions, 25% of inpatients between midnight and 8am

(Not known for 14% of inpatients)

Out of hours presentation

Service provision & mortality

0

5

10

15

20

25

30

35

40

Mortality

0 to 2 3 to 5 6 to 8 >8

Rockall score

OOH rota

No OOH rota

0

20

40

60

80

100

ICCU HDU AUGIB Radiology Blood

transfusion

Facilities available in hospitals

admitting patients with AUGIB

15 sites

unit

Risk adjusted mortality in these hospitals no different to UK figure

Endoscopy services

58% of hospitals have daily emergency endoscopy slot Mon-Fri

50% of patients having endoscopy had it within 24 hours

Rockall score little impact on time to first endoscopy

50% of score 3+ and 43% score 5+ waited more than 24hours

Endoscopists 51% endoscopies performed by consultants

32% performed by trainees – 60% of these unsupervised

56% of hospitals have formal OOH rota for endoscopy

14% of OOH endoscopies - unsupervised trainees

WHAT CAN BE DONE?

All high risk patients with UGIB should be endoscoped within 24 hours, preferably on a planned list in the first instance. For patients who require more urgent intervention either for endoscopy, interventional radiology or surgery formal 24/7 arrangements must be available.

Timing of endoscopy Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation. Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding. Units seeing more than 330 cases a year should offer daily endoscopy lists. Units seeing fewer than 330 cases a year should arrange their service according to local circumstances. NICE 2012

UK IBD Audit

All patients with suspected UGIB should be properly assessed and risk scored on presentation. All patients should be resuscitated prior to therapeutic intervention.Time to diagnostic or therapeutic intervention for your patients All high risk patients with UGIB should be endoscoped within 24 hours, preferably on a planned list in the first instance. For patients who require more urgent intervention either for endoscopy, interventional radiology or surgery formal 24/7 arrangements must be available.

Encourage providers to participate

(Nossiter & Black , Brit J Healthcare Mgt 2011)

2010

in 2011 fallen to 14% of Trusts

34% Trusts participating in less than 60% NCAs

Results

Mortality 14% 10%

Inpatients 33% 26% New admissions 11% 7%

Median age 67yrs 68yrs % > 80yrs 28% 27%

1993/4 2007

Results

Mortality 14% 10%

Inpatients 33% 26% New admissions 11% 7%

Median age 67yrs 68yrs % > 80yrs 28% 27%

1993/4 2007

Risk standardised mortality ratios

Measure of difference between observed mortality and expected from audit population

106 hospitals with OOH on call endoscopy

Median RSMR 0.85

83 hospitals without OOH on call endoscopy

Median RSMR 1.02

Characteristics of National Clinical Databases

• Focused on health care/services • National coverage (achieved or intended) • Prospective • On-going • Recruit all patients or representative sample • Collect patient-level data (Other clinical data collections exist but they don’t

meet these criteria eg national confidential enquiries)

Why? Rockall 1993/4

Mortality 14% overall

33% in inpatients; 11% in emergency admissions

Endoscopy use variable

What has changed ?

Early identification of high risk patients

Therapeutic endoscopy

Drug use in AUGIB

And...

Blood transfusion in AUGIB – never audited

Dr Ian Arnott UK IBD Audit Clinical Director Consultant Gastroenterologist

Western General Hospital, Edinburgh, UK

The UK IBD Audit: Past, Present and Future.

On behalf of UK IBD Audit Steering Group

Clinical area Number

Children (inc neonatal) 8

Adult acute & emergency care 10

Long term conditions 7

Surgery/interventional procedures 7

Renal disease 3

Cancer 4

Trauma 3

Psychological conditions/treatments 2

Blood transfusion 2

National clinical audits in England (2012)