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

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. 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. 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. ( 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. 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. 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!!

8. GBS/RS

9. 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 (publications.nice.org.uk/acuteupper-gastrointestinal-bleeding-management-cg141)


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

10. 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

11. Thank
you!

12. 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