Acute Upper GI
Bleeding – how we
got where we are?
Dr Ian Forgacs
29 January 2014
Gut 2013 62: 242-249
UK IBD Audit
Audit system
Research database

National survey

National clinical audits

Network
Data repository
Clinical registries
Nat...
IBD Standards
• Launched between Feb and
April 2009
• Copies sent to trust and Board
CEOs with the 2nd round IBD
Audit res...
British Society of
Gastroenterology

The UK comparative audit of
acute upper gastrointestinal
bleeding
Why?
Rockall 1993/4
Mortality 14% overall
33% in inpatients; 11% in emergency admissions
Endoscopy use variable

What has ...
What were they looking for?
 Changes in mortality
 Is the Rockall score still useful

 Impact of therapeutic endoscopy
...
257 UK hospitals invited

217 hospitals (84%)
8939 cases submitted
Prospective study
Web-based data entry

1090 insufficie...
 10% overall

Mortality

 7% in those who had endoscopy

 45% of deaths were in patients who did not have
endoscopy
Roc...
Out of hours presentation
 44% of hospitals do not have formal out of
hours rota for endoscopy
 60% of patients present ...
Service provision & mortality
40

OOH rota

35

No OOH rota

30
25
Mortality 20
15
10
5
0

0 to 2

3 to 5

6 to 8

Rockall...
Facilities available in hospitals
admitting patients with AUGIB
100
80
60
15 sites

40
20
0

ICCU

HDU

AUGIB

unit

Radio...
Endoscopy services
 58% of hospitals have daily emergency
endoscopy slot Mon-Fri
 50% of patients having endoscopy had i...
Endoscopists
 51% endoscopies performed by consultants
 32% performed by trainees – 60% of these
unsupervised
 56% of h...
All high risk patients with UGIB should be endoscoped within 24
hours, preferably on a planned list in the first instance....
Timing of endoscopy
Offer endoscopy to unstable patients with severe acute
upper gastrointestinal bleeding immediately aft...
UK IBD Audit
All patients with suspected UGIB should be properly assessed and risk scored on
presentation.
All patients should be resus...
Encourage providers to participate
34% Trusts participating
in less than 60% NCAs

2010

in 2011 fallen to 14% of Trusts
(...
Results
Mortality
Inpatients
New admissions

1993/4
14%
33%
11%

Median age

67yrs

% > 80yrs

28%

2007
10%
26%
7%

68yrs...
Results
Mortality
Inpatients
New admissions

1993/4
14%
33%
11%

Median age

67yrs

% > 80yrs

28%

2007
10%
26%
7%

68yrs...
Risk standardised mortality ratios
 Measure of difference between observed mortality
and expected from audit population
...
Characteristics of National Clinical Databases
•
•
•
•
•
•

Focused on health care/services
National coverage (achieved or...
Why?
Rockall 1993/4
Mortality 14% overall
33% in inpatients; 11% in emergency admissions
Endoscopy use variable

What has ...
The UK IBD Audit: Past,
Present and Future.
On behalf of UK IBD Audit
Steering Group
Dr Ian Arnott
UK IBD Audit Clinical D...
National clinical audits in England (2012)
Clinical area

Number

Children (inc neonatal)

8

Adult acute & emergency care...
Dr Ian Forgacs - acute upper GI bleed service provision
Dr Ian Forgacs - acute upper GI bleed service provision
Dr Ian Forgacs - acute upper GI bleed service provision
Dr Ian Forgacs - acute upper GI bleed service provision
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Dr Ian Forgacs - acute upper GI bleed service provision

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Dr Ian Forgacs, President elect of the British society of Gastroenterology sets the context for acute upper GI bleed service provision in England

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Dr Ian Forgacs - acute upper GI bleed service provision

  1. 1. Acute Upper GI Bleeding – how we got where we are? Dr Ian Forgacs 29 January 2014
  2. 2. Gut 2013 62: 242-249
  3. 3. UK IBD Audit
  4. 4. Audit system Research database National survey National clinical audits Network Data repository Clinical registries National clinical databases Clinical databases Audit database Clinical administration system Surveillance system
  5. 5. IBD Standards • Launched between Feb and April 2009 • Copies sent to trust and Board CEOs with the 2nd round IBD Audit results • Circulated to SHAs, Primary Care Trusts, Local Health Boards • Work to establish a political lobby
  6. 6. British Society of Gastroenterology The UK comparative audit of acute upper gastrointestinal bleeding
  7. 7. Why? Rockall 1993/4 Mortality 14% overall 33% in inpatients; 11% in emergency admissions Endoscopy use variable What has changed ? Early identification of high risk patients Therapeutic endoscopy Drug use in AUGIB And... Blood transfusion in AUGIB – never audited
  8. 8. What were they looking for?  Changes in mortality  Is the Rockall score still useful  Impact of therapeutic endoscopy  Use and effect of blood transfusion Is there a relationship between service provision and outcome?
  9. 9. 257 UK hospitals invited 217 hospitals (84%) 8939 cases submitted Prospective study Web-based data entry 1090 insufficient data 1099 not UGIB 6750 analysed (76%)
  10. 10.  10% overall Mortality  7% in those who had endoscopy  45% of deaths were in patients who did not have endoscopy Rockall score 0-2 (1408) 3-5 (2204) 6-7 (942) ≥8 (435) Expected Observed deaths deaths (1993/4 risk) 2007 2 143 201 179 13 125 122 110 Relative risk (95% CI) 7.6 (3.49 to 5.85) 0.9 (0.73 to 1.05) 0.6 (0.55 to 0.78) 0.6 (0.50 to 0.74)
  11. 11. Out of hours presentation  44% of hospitals do not have formal out of hours rota for endoscopy  60% of patients present out of hours  19% of new admissions, 25% of inpatients between midnight and 8am (Not known for 14% of inpatients)
  12. 12. Service provision & mortality 40 OOH rota 35 No OOH rota 30 25 Mortality 20 15 10 5 0 0 to 2 3 to 5 6 to 8 Rockall score >8
  13. 13. Facilities available in hospitals admitting patients with AUGIB 100 80 60 15 sites 40 20 0 ICCU HDU AUGIB unit Radiology Blood transfusion Risk adjusted mortality in these hospitals no different to UK figure
  14. 14. Endoscopy services  58% of hospitals have daily emergency endoscopy slot Mon-Fri  50% of patients having endoscopy had it within 24 hours  Rockall score little impact on time to first endoscopy  50% of score 3+ and 43% score 5+ waited more than 24hours
  15. 15. Endoscopists  51% endoscopies performed by consultants  32% performed by trainees – 60% of these unsupervised  56% of hospitals have formal OOH rota for endoscopy  14% of OOH endoscopies - unsupervised trainees WHAT CAN BE DONE?
  16. 16. All high risk patients with UGIB should be endoscoped within 24 hours, preferably on a planned list in the first instance. For patients who require more urgent intervention either for endoscopy, interventional radiology or surgery formal 24/7 arrangements must be available.
  17. 17. Timing of endoscopy Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation. Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding. Units seeing more than 330 cases a year should offer daily endoscopy lists. Units seeing fewer than 330 cases a year should arrange their service according to local circumstances. NICE 2012
  18. 18. UK IBD Audit
  19. 19. All patients with suspected UGIB should be properly assessed and risk scored on presentation. All patients should be resuscitated prior to therapeutic intervention.Time to diagnostic or therapeutic intervention for your patients All high risk patients with UGIB should be endoscoped within 24 hours, preferably on a planned list in the first instance. For patients who require more urgent intervention either for endoscopy, interventional radiology or surgery formal 24/7 arrangements must be available.
  20. 20. Encourage providers to participate 34% Trusts participating in less than 60% NCAs 2010 in 2011 fallen to 14% of Trusts (Nossiter & Black , Brit J Healthcare Mgt 2011)
  21. 21. Results Mortality Inpatients New admissions 1993/4 14% 33% 11% Median age 67yrs % > 80yrs 28% 2007 10% 26% 7% 68yrs 27%
  22. 22. Results Mortality Inpatients New admissions 1993/4 14% 33% 11% Median age 67yrs % > 80yrs 28% 2007 10% 26% 7% 68yrs 27%
  23. 23. Risk standardised mortality ratios  Measure of difference between observed mortality and expected from audit population  106 hospitals with OOH on call endoscopy  Median RSMR 0.85  83 hospitals without OOH on call endoscopy  Median RSMR 1.02
  24. 24. Characteristics of National Clinical Databases • • • • • • Focused on health care/services National coverage (achieved or intended) Prospective On-going Recruit all patients or representative sample Collect patient-level data (Other clinical data collections exist but they don’t meet these criteria eg national confidential enquiries)
  25. 25. Why? Rockall 1993/4 Mortality 14% overall 33% in inpatients; 11% in emergency admissions Endoscopy use variable What has changed ? Early identification of high risk patients Therapeutic endoscopy Drug use in AUGIB And... Blood transfusion in AUGIB – never audited
  26. 26. The UK IBD Audit: Past, Present and Future. On behalf of UK IBD Audit Steering Group Dr Ian Arnott UK IBD Audit Clinical Director Consultant Gastroenterologist Western General Hospital, Edinburgh, UK
  27. 27. National clinical audits in England (2012) Clinical area Number Children (inc neonatal) 8 Adult acute & emergency care 10 Long term conditions 7 Surgery/interventional procedures 7 Renal disease 3 Cancer 4 Trauma 3 Psychological conditions/treatments 2 Blood transfusion 2
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