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British Society of Gastroenterology. UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood. Prepared by John Grant-Casey & Sarah Hearnshaw. South West RTC. April 2008. The National Comparative Audit Programme. Background information.

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UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood

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Uk comparative audit of upper gastrointestinal bleeding and the use of blood

British Society ofGastroenterology

UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood

Prepared by

John Grant-Casey & Sarah Hearnshaw

South West RTC

April 2008


The national comparative audit programme

The National Comparative Audit Programme

Background information

  • Series of audits to look at use & administration of blood and blood components

  • All UK NHS Trusts and Independent hospitals

  • Collaborative programme between NHS Blood and Transplant and the Royal College of Physicians

  • Supported by the Healthcare Commission


Acute upper gastrointestinal bleeding augib

Acute Upper Gastrointestinal Bleeding (AUGIB)

Why was this audit necessary?

  • AUGIB common (100/100,000)

  • High mortality (14% in 1993)

  • Large demand on gastroenterology/transfusion services

  • Changes to practice since last audit (1993/4)

    • Therapeutic endoscopy

    • Resuscitation

    • Drugs


Acute upper gastrointestinal bleeding augib1

Acute Upper Gastrointestinal Bleeding (AUGIB)

Why was this audit necessary?

  • AUGIB uses >13% of red blood cells

  • Wide variation in practice

  • Need to identify inappropriate use

  • Service provision patchy

    • -relationship to outcomes?


What were the audit aims

Acute Upper Gastrointestinal Bleeding(AUGIB)

What were the audit aims?

Survey organisation of care

Audit process of care against accepted standards.

Audit transfusion in AUGIB

Examine variation in practice

Assess validity and utility of Rockall (risk-assessment) score

Work with hospitals and stakeholders to reduce variation in care, and improve outcomes


Participation

Acute Upper Gastrointestinal Bleeding(AUGIB)

Participation

Who was invited

  • 257 NHS hospitals from UK

    Who took part

  • 217 (84%) hospitals sent any information

  • 200 (78%) hospitals sent both organisational and case data

  • South West RTC = 594 cases


Uk comparative audit of upper gastrointestinal bleeding and the use of blood

Data from 217 hospitals (84%)

8939 cases submitted

1090 insufficient data

1099 not AUGIB

6750 analysed

82% new admissions 18% inpatients


Participation1

Participation


Methodology

Acute Upper Gastrointestinal Bleeding(AUGIB)

Methodology

Clinical end-points

Service provision

AUDIT STANDARDS

PILOT

DATA COLLECTION

ANALYSIS

All suspected AUGIB

1/5/7- 30/6/7

Online data entry

CEEU

+

Steering group


Acute upper gastrointestinal bleeding augib2

Acute Upper Gastrointestinal Bleeding (AUGIB)

RESULTS - Organisation of care - UK

55% OOH consultant on call rota (n=106)

62% of these ≥ 6 on rota

41% have endoscopy nurse on call

74% consultants on call competent at 4 haemostatic procedures

80% have local guidelines for AUGIB

49% have separate written guidelines for transfusion


Results process of care admissions

Acute Upper Gastrointestinal Bleeding(AUGIB)

RESULTS Process of care: Admissions

% admitted by Gastroenterology/GI bleeding team


Process of care admissions

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Admissions

% admitted out of hours


Process of care assessment

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Assessment

% having risk assessment score calculated and recorded


Process of care assessment1

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Assessment

% with initial Rockall score 3 or more at presentation


Process of care transfusion

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Transfusion

% patients transfused with RBC as part of initial resuscitation

In the UK 33% of patients received a red blood cell transfusion. Regional average = 38%


Process of care transfusion uk data

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Transfusion – UK data

15% of RBC transfusions deemed inappropriate

(Hb ≥10g/dL and haemodynamically stable)

3% received platelets – 42% deemed inappropriate

7% received FFP – 27% deemed inappropriate

57% of patients with INR >1.5 did not get FFP

8% (473/6750) on warfarin

87% of warfarin stopped

50% received Vitamin K


Process of care endoscopy

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Endoscopy

% of patients having first endoscopy within 24 hours of presentation


Process of care endoscopy1

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Endoscopy

% having first endoscopy out of hours


Process of care endoscopic diagnoses

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Endoscopic diagnoses

% with endoscopic diagnosis of varices


Process of care endoscopic diagnoses1

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Endoscopic diagnoses

% with endoscopic diagnosis of PUD


Process of care endoscopy2

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Endoscopy

  • 51% first endoscopies by consultants

  • 82% first endoscopies in hours

  • 1% had complication of endoscopy

  • 19% (1275/6750) received endoscopic therapy

    • Increased with second (43%) and third (51%) endoscopies

  • Dual therapy used in 6% at first endoscopy


Process of care endoscopy3

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Endoscopy

% receiving endoscopic therapy for oesophageal varices at first endoscopy


Process of care endoscopy4

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Endoscopy

% receiving endoscopic therapy for actively bleeding ulcer at first endoscopy


Process of care endoscopy5

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Endoscopy

% receiving endoscopic therapy for non-bleeding visible vessel at first endoscopy


Process of care therapy after endoscopy

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Therapy after endoscopy

% receiving iv PPI after endoscopic therapy to peptic ulcer


Process of care diagnoses

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Diagnoses

32%

SRH

6%

1993


Process of care risk assessment

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Risk assessment

% with final Rockall score 6 or more


Process of care outcomes

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Outcomes

% discharged within 7 days of presentation


Process of care outcomes1

Acute Upper Gastrointestinal Bleeding(AUGIB)

Process of care: Outcomes

% mortality, % alive in hospital at 28 days, and % discharged within 28 days – for all patients


Process of care outcomes2

Acute Upper Gastrointestinal Bleeding(AUGIB)

Risk standardised mortality ratio

Process of care: Outcomes


Service provision and outcomes

Acute Upper Gastrointestinal Bleeding(AUGIB)

Service provision and outcomes


Discussion

Acute Upper Gastrointestinal Bleeding(AUGIB)

Discussion

Variation in audit support – significant impact on number of completed cases

Variation in case identification – selection bias

Need for more warning, less arduous audit tool if repeated

Concern re timing of audit; insufficient time for data entry

Missing data – 12%

Cannot accurately measure incidence


Conclusions

Acute Upper Gastrointestinal Bleeding(AUGIB)

Conclusions

Largest ever audit of AUGIB in UK

Be encouraged – reduction in mortality despite increase in varices

44% have no formal on call rota for endoscopy OOH

60% of AUGIB patients present OOH

Why no impact on outcomes – good will?

Transfusion variable – need to review local and regional guidelines and consider how to reduce inappropriate use


Acknowledgements

Acute Upper Gastrointestinal Bleeding(AUGIB)

  • Hospital staff who collected the audit data

  • Project team:

    Dr Sarah Hearnshaw

    Mr John Grant-Casey

    Mr Derek Lowe

    Prof Richard Logan

    Prof Tim Rockall

    Dr Simon Travis

    Prof Mike Murphy

    Dr Kel Palmer

Acknowledgements


Uk comparative audit of upper gastrointestinal bleeding and the use of blood

British Society ofGastroenterology

UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood

Prepared by

John Grant-Casey & Sarah Hearnshaw

South West RTC

April 2008


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