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Prof Sauid Ishaq - acute upper GI bleed service Dudley


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Professor Sauid Ishaq, Professor of Medicine and Gastroenterology
DGOH describes the acute upper GI bleed service model in Dudley

Published in: Health & Medicine
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Prof Sauid Ishaq - acute upper GI bleed service Dudley

  1. 1. GI bleed- what matters Dudley experience Dr Sauid Ishaq Gastroenterologist DGOH DUDLEY National Upper GI bleed Workshop 29th Jan 2014 ( NHS improving quality)
  2. 2. UK Comp a r a t i v e Au d i t o f UGI Bl e e d i n g a n d t h e Use o f Bl o o d December 2007 Mortality 10% (was 14%)  Risk assessment using a validated scoring system  AUGIB- high risk - inpatients, elderly, high score- identify  Early access to specialist care  One Third of Varices/ AUGIB do not have a therapeutic procedure performed- ?  Provision for gastroscopy within 24 hours- high risk group
  3. 3. UK Comparative audit of Upper GI bleeding and Blood use  Acute upper GI bleeding accounts for 13% of all blood use  38% in West Midlands transfused rbc  6750 cases analysed  13% of rbc transfusions deemed inappropriate  Hb>100g/l and stable  42% of platelets given were inappropriate  27% of FFP was given inappropriately  57% with INR>1.5 not given FFP
  4. 4. ( patient story-Ray Bagshaw )  I am writing following a relatively short stay at Russells Hall with a message of sincere gratitude from the bottom of my heart.  On Tuesday 23 July I collapsed at home with a massive gastric bleed, my BP was 45/30 and I was haemorrhaging, when Ambulance and Paramedics arrived I barely had a pulse, and I was later told by staff literally one more minute and I would have died. Upon arrival I was taken to Resuscitation where a Doctor and Nurse worked on me and stayed with me for over 2 hours.  I found nothing short of exemplary medical and nursing care. It is often the case that people are ready to complain and criticise but I wish to write with the contrary. Dr Ishaq and his team were outstanding in their care and intervention  It is not an exaggeration that I owe my life to the staff, without them I would not be here, I cheated death as I put it whilst I was in Hospital but the truth is that I had a full team of professionals who would not give up on me and refused to let me go.  I will never forget and neither should I the people concerned and as I said gratitude is not enough I am indebted to Russells Hall Hospital Centre of Excellence and the staff to whom I and my family literally owe my life.  With the kindest regards to you and everyone, thank you from the bottom of my heart.
  5. 5. Russells Hall Hospital  Dudley population, 400000  6 Gastroenterologist (were 4 in 2007)  OOH endoscopy on-call  250-300 GI bleed per year  GI bleed admit under on-call consultant  GI ward when bed comes up-  Resuscitation ? Time of day and week  Endoscopy? delay  Monitoring? – general medical ward
  6. 6. Listening In Action exercise (LIA)  LIA initiative led by Chief executive  Group discussions of core enthusiasts from EAU, A&E, Nurses, Endoscopy coordinator, haematology department, surgical and medial SpRs.  Brainstorming- highlighting real issues/ barriers around care, share personal experiences, possible solutions,  Recommendations to improve care of AUGIB  GI bleed champions- senior nurses in EAU  All new GI patients seen by GI Consultant  Ring fenced GI bleed slot – 7/ week  Rolling audit of GI bleed related death in Mortality meeting  Most difficult part- to bring about the change!!
  7. 7. GBS/RS
  8. 8. Protected Endoscopy Slots for Acute Upper Gastrointestinal Bleed(AUGIB)   62 cases of AUGIB from pre protected & 59 from post protected slot system Primary Aim: Measure service improvement i.e. endoscopy with in 24 hours admission/event for all AUGIB patients (   Small study to show any effect on mortality No adverse effect on out patient waiting times; unused AUGIB slots filled with inpatients waiting endoscopy for other reasons Pre Protected Slot System Jul10-Jun11 Post Protected Slot System Jul11-Jun12 89% (32/36) 97% (28/29) Endoscopy with in 24 hours Non-Emergency Cases 54% (14/26) 73% (22/30) Less than 14 days Hospital Stay 32% (20/62) 20% (12/59) Endoscopy with in 24 hours Emergency Cases
  9. 9. Top Tips  Dedicated endoscopists/nurses with a GI bleed lead that inspires to bring change by involving others, engage and make team members stakeholders.  An awareness campaign ( GI bleed champions) , advertise the service and the standards expected, continued education and feedback (FY/CT/Nurses/ITU/A&E/,EAU. Haematologist, Physician and Surgeon))  Identify the root cause of problems (identify high risk patient, resuscitation, senior review, monitoring) and how to tackle them  Early endoscopy intervention reduces the need for blood transfusion and the associated risks.  Match service demand and capacity appropriately to the day of the week and time. Ring fence these slots  Rolling audit
  10. 10. Thank you!
  11. 11. Appropriate thresholds for transfusion in GI bleeding?  Transfusion Strategies for Acute Upper Gastrointestinal Bleeding  NEJM, January 8, 2013  Liberal (Hb 90) v Restrictive (Hb 70)  Improved survival in restrictive group 95% v 91%   Less adverse events   Less re-bleeds Lower portal-pressure gradient THOUGH -higher mortality in restrictive group with  PUD  Childs-Pugh A or B