1. John Grant-Casey & Sarah Hearnshaw
British Society of Gastroenterology
UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood
This set of slides presents the main findings from the audit and gives comparable data for hospitals in North West RTC.
If you wish, you could augment these slides with local information which will be found in your hospital’s audit report.
Please use or adapt these slides as you require when making a local presentation. .
Prepared by
John Grant-Casey & Sarah Hearnshaw
North West 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
This slide describes the National Comparative Audit programme

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. 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
This slide sets out what we hoped to achieve by conducting the audit.

6. 217 (84%) hospitals sent any information
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
North West RTC =890 cases

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

8. Participation Hospital Code n = 29 Organisational? No. of cases = 890
% regional total A
Yes 47 5 B 78 9 C 45 D 20 2 E 34 4 F No G 37 H 23 3 J 12 1 K 19 L 31 M N 29

9. Participation (Continued)
Hospital Code n = 29
Organisational?
No. of cases = 890
% regional total P
Yes 46 5 Q 36 4 R 66 7 S 19 2 T 35 V 45 W 37 X 38 Y 1 Z AA 24 3 AB AC 16 AD 22 AE 43 AF No 39

10. AUDIT STANDARDS PILOT DATA COLLECTION ANALYSIS Clinical end-points
Acute Upper Gastrointestinal Bleeding (AUGIB)
AUDIT STANDARDS
PILOT
DATA COLLECTION
ANALYSIS
Methodology
Clinical end-points
Service provision
All suspected AUGIB
1/5/7- 30/6/7
Online data entry
CEEU +
Steering group

11. 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

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

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

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

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

16. 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 = 31%

17. 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

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

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

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

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

22. Process of care: Endoscopy
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

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

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

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

26. 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

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

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

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

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

31. Process of care: Outcomes – slide 1
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Outcomes – slide 1
Risk standardised mortality ratio
Hospital
RSMR
95% CI A
1.02
0.13 to 1.91 B
0.61
0.08 to 1.14 C
0.57
-0.07 to 1.21 D
0.82
-0.11 to 1.75 E
0.63
-0.60 to 1.87 G
1.57
0.19 to 2.94 H
0.84
-0.32 to 1.99 J
0.79
-0.10 to 1.67 K
1.21
-0.47 to 2.89 L
0.00 M
0.38
-0.36 to 1.12 N
0.75
-0.10 to 1.60 P Q
1.58
0.03 to 3.12 R
2.14
0.74 to 3.53

32. Process of care: Outcomes – slide 2
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Outcomes – slide 2
Risk standardised mortality ratio
Hospital
RSMR
95% CI S
1.48
0.18 to 2.78 T
0.33
-0.13 to 0.79 V
0.61
-0.59 to 1.82 W
1.90
0.38 to 3.41 X
0.76
0.02 to 1.50 Y
0.67
-0.09 to 1.42 Z
1.06
0.02 to 2.10 AA AB
1.17
-0.45 to 2.80 AC
0.59
-.057 to 1.76 AD
1.60
-1.54 to 4.74 AE
0.00 AF
2.67
0.53 to 4.81 AG
1.62
0.20 to 3.05 AH
0.71
-0.09 to 1.51

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

34. Variation in case identification – selection bias
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

35. Largest ever audit of AUGIB in UK
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

36. Hospital staff who collected the audit data
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

37. John Grant-Casey & Sarah Hearnshaw
British Society of Gastroenterology
UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood .
Prepared by
John Grant-Casey & Sarah Hearnshaw
North West RTC
April 2008