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

1. British Society ofGastroenterology UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood Prepared by John Grant-Casey & Sarah Hearnshaw East of England RTC April 2008

2. 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

3. 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

4. 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?

5. 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

6. 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 • East of England RTC = 660 cases

7. Data from 217 hospitals (84%) 8939 cases submitted 1090 insufficient data 1099 not AUGIB 6750 analysed 82% new admissions 18% inpatients

8. Participation

9. 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

10. 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

11. Acute Upper Gastrointestinal Bleeding(AUGIB) RESULTS Process of care: Admissions % admitted by Gastroenterology/GI bleeding team

12. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Admissions % admitted out of hours

13. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Assessment % having risk assessment score calculated and recorded

14. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Assessment % with initial Rockall score 3 or more at presentation

15. 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 = 39%

16. 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

17. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Endoscopy % of patients having first endoscopy within 24 hours of presentation

18. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Endoscopy % having first endoscopy out of hours

19. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Endoscopic diagnoses % with endoscopic diagnosis of varices

20. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Endoscopic diagnoses % with endoscopic diagnosis of PUD

21. 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

22. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Endoscopy % receiving endoscopic therapy for oesophageal varices at first endoscopy

23. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Endoscopy % receiving endoscopic therapy for actively bleeding ulcer at first endoscopy

24. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Endoscopy % receiving endoscopic therapy for non-bleeding visible vessel at first endoscopy

25. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Therapy after endoscopy % receiving iv PPI after endoscopic therapy to peptic ulcer

26. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Diagnoses 32% SRH 6% 1993

27. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Risk assessment % with final Rockall score 6 or more

28. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Outcomes % discharged within 7 days of presentation

29. Acute Upper Gastrointestinal Bleeding(AUGIB) Process of care: Outcomes % mortality, % alive in hospital at 28 days, and % discharged within 28 days – for all patients

30. Acute Upper Gastrointestinal Bleeding(AUGIB) Risk standardised mortality ratio Process of care: Outcomes

31. Acute Upper Gastrointestinal Bleeding(AUGIB) Service provision and outcomes

32. 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

33. 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

34. 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

35. British Society ofGastroenterology UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood Prepared by John Grant-Casey & Sarah Hearnshaw East of England RTC April 2008