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  • This set of slides presents the main findings from the audit and gives comparable data for hospitals in the South 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. .
  • This slide describes the National Comparative Audit programme
  • This slide sets out what we hoped to achieve by conducting the audit.
  • This set of slides presents the main findings from the audit and gives comparable data for hospitals in the South 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. .

Transcript

  • 1. UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood Prepared by John Grant-Casey & Sarah Hearnshaw April 2008 South West RTC British Society of Gastroenterology
  • 2. The National Comparative Audit Programme
    • 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
    Background information
  • 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) 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.
    • 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 West RTC = 594 cases
    Participation Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 7.
    • Data from 217 hospitals (84%)
    • 8939 cases submitted
    • 1090 insufficient data
    • 1099 not AUGIB
    • 6750 analysed
    • 82% new admissions 18% inpatients
  • 8. Participation 6 34 Yes D - - Yes F 3 18 Yes G 5 31 Yes H 7 42 Yes J 2 11 Yes K 6 38 Yes W 10 60 Yes V 6 38 Yes T 8 48 Yes R 3 17 Yes Q 10 57 Yes P 1 8 Yes N 5 30 Yes M 14 82 Yes C 7 42 Yes B 6 38 Yes A % regional total No. of cases = 594 Organisational? Hospital Code n = 17
  • 9. Methodology
    • AUDIT STANDARDS
    • PILOT
    • DATA COLLECTION
    • ANALYSIS
    Acute Upper Gastrointestinal Bleeding (AUGIB) Clinical end-points Service provision All suspected AUGIB 1/5/7- 30/6/7 Online data entry CEEU + Steering group
  • 10.
    • 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
    Acute Upper Gastrointestinal Bleeding (AUGIB) RESULTS - Organisation of care - UK
  • 11. RESULTS Process of care: Admissions
    • % admitted by Gastroenterology/GI bleeding team
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 12. Process of care: Admissions
    • % admitted out of hours
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 13. Process of care: Assessment
    • % having risk assessment score calculated and recorded
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 14. Process of care: Assessment
    • % with initial Rockall score 3 or more at presentation
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 15. 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 = 38%
  • 16.
    • 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
    Process of care: Transfusion – UK data Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 17. Process of care: Endoscopy
    • % of patients having first endoscopy within 24 hours of presentation
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 18. Process of care: Endoscopy
    • % having first endoscopy out of hours
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 19. Process of care: Endoscopic diagnoses
    • % with endoscopic diagnosis of varices
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 20. Process of care: Endoscopic diagnoses Acute Upper Gastrointestinal Bleeding (AUGIB) % with endoscopic diagnosis of PUD
  • 21. 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
  • 22. Process of care: Endoscopy
    • % receiving endoscopic therapy for oesophageal varices at first endoscopy
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 23. Process of care: Endoscopy
    • % receiving endoscopic therapy for actively bleeding ulcer at first endoscopy
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 24. Process of care: Endoscopy
    • % receiving endoscopic therapy for non-bleeding visible vessel at first endoscopy
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 25. Process of care: Therapy after endoscopy
    • % receiving iv PPI after endoscopic therapy to peptic ulcer
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 26. Process of care: Diagnoses Acute Upper Gastrointestinal Bleeding (AUGIB) 6% 1993 32% SRH 17 None 3 Vascular malformation 5 Portal Gastropathy 11 Varices 4 Mallory- Weiss 4 Malignancy 13 Erosive duodenitis 36 Ulcer 22 Gastritis/ erosions 24 Oesophagitis % Endoscopic finding
  • 27. Process of care: Risk assessment
    • % with final Rockall score 6 or more
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 28. Process of care: Outcomes
    • % discharged within 7 days of presentation
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 29. Process of care: Outcomes
    • % mortality, % alive in hospital at 28 days, and % discharged within 28 days – for all patients
    Acute Upper Gastrointestinal Bleeding (AUGIB)
  • 30. Process of care: Outcomes Risk standardised mortality ratio Acute Upper Gastrointestinal Bleeding (AUGIB) 0.02 to 1.91 0.97 W 0.42 to 2.02 1.22 V -0.22 to 1.38 0.58 T 0.10 to 1.59 0.85 R -0.25 to 4.05 1.90 Q 0.11 to 1.70 0.91 P -1.16 to 7.18 3.01 N -0.32 to 0.99 0.33 M -0.97 to 5.98 2.51 K -0.08 to 1.36 0.64 J -0.12 to 2.01 0.94 H   0.00 G 0.02 to 1.75 0.89 D 0.22 to 1.49 0.86 C 0.34 to 2.32 1.33 B 0.03 to 2.48 1.25 A 95% CI RSMR Hospital
  • 31. Service provision and outcomes Acute Upper Gastrointestinal Bleeding (AUGIB) 8.2% 7.1% Mortality after OGD 13% 14% Re-bleeding rate 5 days 6 days Median stay 254/1980 (13%) 586/2969 (20%) 1 st Endoscopy OOH No OOH rota (2821) OOH on call rota (3499)
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood Prepared by John Grant-Casey & Sarah Hearnshaw April 2008 South West RTC British Society of Gastroenterology