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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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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
slide7
Data from 217 hospitals (84%)

8939 cases submitted

1090 insufficient data

1099 not AUGIB

6750 analysed

82% new admissions 18% inpatients

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

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 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 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

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
slide35
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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