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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
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
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
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
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
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
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
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

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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  • 1. Acute Upper GI Bleeding – how we got where we are? Dr Ian Forgacs 29 January 2014
  • 2. Gut 2013 62: 242-249
  • 3. UK IBD Audit
  • 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. 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. British Society of Gastroenterology The UK comparative audit of acute upper gastrointestinal bleeding
  • 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. 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. 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% 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. 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. 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. 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. 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. 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. 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. 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. UK IBD Audit
  • 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. 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. Results Mortality Inpatients New admissions 1993/4 14% 33% 11% Median age 67yrs % > 80yrs 28% 2007 10% 26% 7% 68yrs 27%
  • 22. Results Mortality Inpatients New admissions 1993/4 14% 33% 11% Median age 67yrs % > 80yrs 28% 2007 10% 26% 7% 68yrs 27%
  • 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. 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. 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. 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. 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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