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
Prepared by John Grant-Casey Sarah Hearnshaw
South Central RTC
April 2008
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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

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Acute Upper Gastrointestinal Bleeding (AUGIB)
Why was this audit necessary?
AUGIB common (100/100,000) High mortality (14 in
1993) Large demand on gastroenterology/transfusi
on services Changes to practice since last
audit (1993/4) Therapeutic endoscopy Resuscitation
Drugs
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Acute Upper Gastrointestinal Bleeding (AUGIB)
Why was this audit necessary?

• AUGIB uses gt13 of red blood cells
• Wide variation in practice
• Need to identify inappropriate use
• Service provision patchy
• -relationship to outcomes?

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What were the audit aims?
Acute Upper Gastrointestinal Bleeding (AUGIB)
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
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Participation
Acute Upper Gastrointestinal Bleeding (AUGIB)

• 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 Central RTC 430 cases

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

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Participation
Hospital Code n 13 Organisational? No. of cases 430 regional total
A Yes 9 2
B Yes 14 3
C Yes 65 15
D Yes 6 1
E Yes 29 7
F Yes 30 7
G Yes 27 6
H Yes 10 2
J Yes 50 12
K Yes 13 3
L Yes 60 14
M Yes 76 18
N Yes 41 10
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Methodology
Acute Upper Gastrointestinal Bleeding (AUGIB)

• AUDIT STANDARDS
• PILOT
• DATA COLLECTION
• ANALYSIS

Clinical end-points Service provision
All suspected AUGIB 1/5/7- 30/6/7 Online data
entry
CEEU Steering group
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Acute Upper Gastrointestinal Bleeding (AUGIB)
RESULTS - Organisation of care - UK

• 55 OOH consultant on call rota (n106)
• 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

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RESULTS Process of care Admissions
Acute Upper Gastrointestinal Bleeding (AUGIB)

• admitted by Gastroenterology/GI bleeding team

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Process of care Admissions
Acute Upper Gastrointestinal Bleeding (AUGIB)

• admitted out of hours

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Process of care Assessment
Acute Upper Gastrointestinal Bleeding (AUGIB)

• having risk assessment score calculated and
  recorded

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Process of care Assessment
Acute Upper Gastrointestinal Bleeding (AUGIB)

• with initial Rockall score 3 or more at
  presentation

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Process of care Transfusion
Acute Upper Gastrointestinal Bleeding (AUGIB)
patients transfused with RBC as part of initial
resuscitation

In the UK 33 of patients received a red blood
cell transfusion. Regional average 43
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Process of care Transfusion UK data
Acute Upper Gastrointestinal Bleeding (AUGIB)

• 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 gt1.5 did not get FFP
• 8 (473/6750) on warfarin
• 87 of warfarin stopped
• 50 received Vitamin K

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Process of care Endoscopy
Acute Upper Gastrointestinal Bleeding (AUGIB)

• of patients having first endoscopy within 24
  hours of presentation

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Process of care Endoscopy
Acute Upper Gastrointestinal Bleeding (AUGIB)

• having first endoscopy out of hours

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Process of care Endoscopic diagnoses
Acute Upper Gastrointestinal Bleeding (AUGIB)

• with endoscopic diagnosis of varices

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Process of care Endoscopic diagnoses
Acute Upper Gastrointestinal Bleeding (AUGIB)
with endoscopic diagnosis of PUD
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Process of care Endoscopy
Acute Upper Gastrointestinal Bleeding (AUGIB)
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
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Process of care Endoscopy
Acute Upper Gastrointestinal Bleeding (AUGIB)

• receiving endoscopic therapy for oesophageal
  varices at first endoscopy

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Process of care Endoscopy
Acute Upper Gastrointestinal Bleeding (AUGIB)

• receiving endoscopic therapy for actively
  bleeding ulcer at first endoscopy

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Process of care Endoscopy
Acute Upper Gastrointestinal Bleeding (AUGIB)

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

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Process of care Therapy after endoscopy
Acute Upper Gastrointestinal Bleeding (AUGIB)

• receiving iv PPI after endoscopic therapy to
  peptic ulcer

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Process of care Diagnoses
Acute Upper Gastrointestinal Bleeding (AUGIB)
Endoscopic finding
Oesophagitis 24
Gastritis/ erosions 22
Ulcer 36
Erosive duodenitis 13
Malignancy 4
Mallory- Weiss 4
Varices 11
Portal Gastropathy 5
Vascular malformation 3
None 17
32 SRH
6 1993
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Process of care Risk assessment
Acute Upper Gastrointestinal Bleeding (AUGIB)

• with final Rockall score 6 or more

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Process of care Outcomes
Acute Upper Gastrointestinal Bleeding (AUGIB)

• discharged within 7 days of presentation

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Process of care Outcomes
Acute Upper Gastrointestinal Bleeding (AUGIB)

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

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Process of care Outcomes
Acute Upper Gastrointestinal Bleeding (AUGIB)
Risk standardised mortality ratio
Hospital RSMR 95 CI
A 1.56 -0.60 to 3.73
B 0.58 -0.56 to 1.72
C 1.08 0.21 to 1.94
D    
E 1.33 -0.18 to 2.84
F 1.72 0.21 to 3.23
G 1.72 0.34 to 3.10
H    
J 0.67 -0.09 to 1.42
K 1.92 -0.25 to 4.09
L 1.01 0.20 to 1.82
M 1.16 0.35 to 1.96
N 0.58 -0.22 to 1.37
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Service provision and outcomes
Acute Upper Gastrointestinal Bleeding (AUGIB)
OOH on call rota (3499) No OOH rota (2821)
1st Endoscopy OOH 586/2969 (20) 254/1980 (13)
Re-bleeding rate 14 13
Median stay 6 days 5 days
Mortality after OGD 7.1 8.2
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Discussion
Acute Upper Gastrointestinal Bleeding (AUGIB)
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
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Conclusions
Acute Upper Gastrointestinal Bleeding (AUGIB)

• 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

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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

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UK Comparative Audit of Upper Gastrointestinal
Bleeding and the Use of Blood
Prepared by John Grant-Casey Sarah Hearnshaw
South Central RTC
April 2008