1. National Comparative Audit of Lower
Gastrointestinal Bleeding and the Use of Blood:
FINDINGS AND INTERPRETATIONS
Raimundas Lunevicius, Jūratė Noreikaitė, Mohammed Elniel
Grand Rounds
Aintree University Hospital NHS FoundationTrust
Liverpool
Nov 15th, 2016
10/12/2016 1

2. Agenda for 20-25 minutes
• The necessity of this audit
• Methods
• Results: key finding
– at the national and site-specific levels ( Aintree)
• Interpretations
– ‘MD Bulletin’ to mention
Introduction
10/12/2016 2

3. Problem
• 19,000 admissions with LGIB / UK / year
• Becoming much more common
• Practice is suboptimal; assumption based on concerns:
– re inappropriate use of blood components in GIB
– re too small proportion of pts undergoes investigations during index adm.
• An objective evaluation of performance against a set of standards to
produce a piece of evidence was required to understand the processes of
care and outcomes, and to identify areas for improvement
Introduction
10/12/2016 3

4. Initiatives and funding
• Stakeholders
– NHS Blood and Transplant
– Association of Coloproctology of Great Britain and Ireland
– British Society of Gastroenterology
– British Society of Interventional Radiology
• Funding
– NHS Blood and Transplant & the Bowel Disease Research Foundation
• Report
– Online
– Aintree specific results are NOT available online
10/12/2016 4
Introduction

5. Methods
10/12/2016 5

6. Hospitals, criteria, time-frame
• 174 hospitals of 4 constituent countries of the UK invited
• Duration: 1 Sep 2015 - 31 Oct 2015
• The cases / inclusion criteria:
– Adults ≥16
– Admission with PR bleeding without haematemesis
– Admission and ≥24 hours stay in the hospital
– Inpatient with other underlying illness and PR bleeding
• 28 days given for observation of a patient and data collection
• The electronic questionnaire included 180 questions
• Set of 17 standards declared
Methods
10/12/2016 6

7. No national guideline and standards for LGIB
How the standards for audit been selected?
• Guidelines adapted for this audit
• From six resources as 17 specific point standards
• Resources:
1. SIGN 2008 (Scotland)
2. NCEPOD report on GI bleeding
3. BSG and NICE guidelines on UGIB
4. BCSH and NICE guidelines on the use of blood components
5. Recommendations made by ASGBI, NELA, BSIR
6. Consensus opinions
Methods
10/12/2016 7

8. 17 standards for
• Clin. Examination & Bedside tests: 1,2
• LaboratoryTests for LGIB: 3
• Medicines Management: 4, 5, 6, 7
• Blood ComponentTransfusion: 8 – 12
• The Investigation of LGIB: 13, 14
• Surgery: 15 – 17
Methods
6%
12%
12%
18%
23%
29%
0% 5% 10% 15% 20% 25% 30% 35%
Laboratory tests
Clinical examination and blood tests
Investigation of LGIB
Surgery
Medicines management
Blood component transfusion
Percentage weight of a cluster of standards
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9. Results
10/12/2016 9

10. Identified & eligible cases
Results
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11. Participation: UK
• 143 / 174 hosp. provided patient or organization of care spec. data
• 139/143: provided data on 2,528 patients
• Average identified potential & eligible cases per site was
– 20 potential & 18 eligible cases in two months (1 bleeding in 3-4 days)
• How did Aintree work ?
10/12/2016 11
Results: patient specific

12. Aintree patients
• Identified potential
cases: 78
– 1 or 2 patients a day
• Eligible cases: 52
10/12/2016 12
30
14
5 5
4
20
0
5
10
15
20
25
30
35
EGSU Gastro ITU Ward 20 AMU Other 12
wards
Patients
Results: patient specific

13. UK: key findings (n= 2,528)
• Median age 74
• M / F: 1:1
• Comorbidities: 79% hypertension, DM, chronic respiratory disease
• On oral anti-platelet or anticoagulant: 43%
• RBC: 27%
• CT-scan of the abdomen & pelvis: 21%
• Invasive mesenteric angiography: 1.5% (37)
• Angio-embolisation: 0.8% (19)
• Flexible sigmoidoscopy or colonoscopy whilst admission:26%
Results: patient specific
10/12/2016 13

14. UK: key findings (n= 2,528)
• Proportion of no inpatient investigations to
identify a source of bleeding: 49%
• Laparotomy for LGI bleeding: 0.2% (6)
• Trans-anal surgery for bleeding: 1.1% (26)
• Re-admission rate within 28 days: 13% (260)
• Mortality at 28 days: 3.4% (85)
Results: patient specific
10/12/2016 14

15. Organisation specific findings N=143
• 73% (104 / 143)
– provide onsite 24/7 access to LGI endoscopy
• 55% (79)
– reported 24/7 onsite or network access to IR
• 21% (30)
– reported that elderly patients with LGIB were
reviewed by DME physicians (!)
Results: organisation of care specific
10/12/2016 15

16. Performance against 17 standards
• UK
• Aintree (site)
Results
10/12/2016 16
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8A 8B 9 10 11 12 13 14 15 16 17
Number of a standard
Performance (practice) = standards (theory)

17. UK vs. Aintree
National cohort: UK (2528) Site: Aintree (52)
0
10
20
30
40
50
60
70
80
90
100
16 3 10 17 11 15 8B 7 2
Percentage
Number of a concrete standard
Standard
Performance
0
10
20
30
40
50
60
70
80
90
100
10 4 3 1 5 11 13 8A 8B 14 2 7 9 12
Percentage
Number of a concrete standard
Standard
Performance
Results
10/12/2016 17

18. Clinical Examination & Bedside tests:
standards 1 and 2
Standard – % (n) of patients meeting / met the standard UK: 2528 Site: 52
1. All pts. admitted with LGIB should undergo DRE (SIGN 2008) 86.7%
2191
71.1%
38
2. All pts. with rectal bleeding should undergo
proctoscopy or rigid sigmoidoscopy (SIGN 2008)
3.4%
73/2178
0%
0/48
Results
0
10
20
30
40
50
60
70
80
90
100
1 2
Standard
UK
Aintree
10/12/2016 18

19. LaboratoryTests for LGIB: standard 3
Standard – % (n) of patients meeting / met the standard UK: 2528 Site: 52
3. LGIB: should have a FBC, coagulation screen, biochemistry
(consensus opinion)
84.5%
2135
86.5%
45
Results
10/12/2016 19
0
10
20
30
40
50
60
70
80
90
100
Standard UK Aintree

20. Medicines Management: standards 4-7
Standard – % (n) of patients meeting / met the standard UK: 2528 Site: 52
4. Continue low dose aspirin for secondary prevention of vascular
events in patients with LGI bleeding in whom haemostasis have been
achieved (EH / IR) or are considered to have stopped bleeding
spontaneously (developed from NICE 2012)
78.7%
424/539
87.5%
7/8
5. Stop other NSAIDs (incl. cyclooxygenase-2 inhibitors) during the
acute phase in pts. presenting with LGIB (developed from NICE 2012)
61%
89/146
33.3%
1/3
6. Emergency anticoagulation reversal in major haemorrhage (53 pts
– 2%) should be with 25-50 U/kg PCC and 5 mgVit. K IV (BSCH 2013)
40%
2/5
No data
breakdown
by site
7. Reversal for non-clinically significant bleeding should be with 1-3
mg IV vitamin K (BCSH 2013): 10.8% (270) were taken warfarin
18.2%
(20/262)
0%
(0/4)
Results
10/12/2016 20

21. Medicines Management: standards 4-7
10/12/2016 21
0
10
20
30
40
50
60
70
80
90
100
4 5 6 7
Percentage
Number of standard
Standard
UK
Aintree

22. Blood ComponentTransfusion: 8- 12
Standard – % (n) of patients meeting / met standard UK: 2528 Site: 52
8A. Use restrictive RBC transfusion thresholds (70 g/L) for pts. who
need RBC transfusions and who do not have major haemorrhage
(MH) or acute coronary syndrom (ACS) (NICE 2015)
8B. Use a HB concentration target of 70-90 g/L after transfusion for
pts. who need RBCTs & who don’t have MH or ACS (NICE 2015)
19.5%
(117/599)
19.2%
(115/599)
23.1%
(3/13)
23.1%
(3/13)
9. Offer platelet transfusion to pts. with LGIB who have significant
bleeding & have a platelet count of less than 30 (dev. from NICE
2015)
0%
0/44
0%
0/2
10. Don’t routinely give more than a single adult dose of platelets in
a transfusion
75.0%
(33/44)
100%
(2/2)
11. In LGIB, offer FFP to patients who have either an INR or APTT
ratio greater than 1.5 times normal (developed from NICE 2012)
26.8%
(15/56)
33.3%
(1/3)
12. Use a dose of at least 15 ml/kg when giving FFT trans (NICE 2015) 7.1% (4/56) 0%
Results
10/12/2016 22

23. Blood ComponentTransfusion: 8- 12
0
10
20
30
40
50
60
70
80
90
100
8A 8B 9 10 11 12
Percentage
Number of standard
Standard
UK
Aintree
Results
10/12/2016 23

24. The Investigation of LGIB: 13, 14
Standard – % (n) of patients meeting / met standard UK: 2528 Site: 52
13.The cause and site of clinically significant LGIB should be
determined following the early use (within 24 hours) of colonoscopy
or flexible sigmoidoscopy or the use of CT-angiography or digital
subtraction angiography (developed from SIGN 2008)
25%
(9/36)
31.3%
(5/16)
14. Patients with LGIB with clinically significant bleeding should
have an OGD unless the cause has been established using another
modality of investigation within 24 hours (dev. from NICE 2012)
19%
(4/21)
14.3%
(1/7)
Results
0 20 40 60 80 100
Standard
UK
Aintree
Percentage
14
13
10/12/2016 24

25. Surgery: 15-17
Standard – % (n) of patients meeting / met standard UK: 2528 Site: 52
15.When surgery is contemplated, a formal assessment of the risk
death & complications should be undertaken by a clinician &
documented (adapted from ASGBI 2012 and NELA 2015)
22.9%
(11/48)
No data
breakdown
by site
16. Surgical procedures with a predicted mortality > 10% should be
conducted under the direct supervision of a consultant surgeon
(CCT holder) and consultant anaesthetist unless the consultants are
satisfied that the delegated staff have adequate competency,
experience, manpower and are adequately free of competing
responsibilities (ASGBI 2012)
100% (3/3) No data
breakdown
by site
17. Localised segmental intestinal resection or subtotal colectomy
is recommended for the management of colonic haemorrhage
uncontrolled by other techniques (SIGN 2008)
60%
(3/5)
No data
breakdown
by site
Results
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26. Surgeries in 139 hospitals of the UK: 5
/ 2528
Surgery Indication Patients Deaths
Right hemi-colectomy Angiodysplasia
Diverticular bleed
2 0
Subtotal colectomy Non-Hodgkin’s lymphoma
Diverticular bleed
2 2
Anterior rectum resection Rectum cancer 1 0
10/12/2016 26
Mortality rate – 40% (2 deaths, 5 patients)

27. Aintree-specific findings
• Only 60% had their NSAIDs withheld
• 1 out of 10 of patients with PR bleeding – on warfarin.
– the vast majority of them didn’t receive appropriate PCC or vitamin K
• Although presentation with shock was rare , 25% received RBCs
– many of these transfusions may be deemed inappropriate.
• A 1/3 of patients that had significant bleeding didn’t have the
source of their bleeding investigated
– of those that underwent investigation, many waited more than 24 h
• No patients required emergency laparotomy
10/12/2016 27
Results

28. UK vs. Aintree
National cohort: UK (2528) Site: Aintree (52)
0
10
20
30
40
50
60
70
80
90
100
16 3 10 17 11 15 8B 7 2
Percentage
Number of a concrete standard
Standard
Performance
0
10
20
30
40
50
60
70
80
90
100
10 4 3 1 5 11 13 8A 8B 14 2 7 9 12
Percentage
Number of a concrete standard
Standard
Performance
Results
10/12/2016 28

29. Interpretation
10/12/2016 29
Water drop-6 , NGS. ©mohammad reza shojaee

30. #1:The term: acute GI bleeding
• NOT
– acute UGI bleeding
– acute LGI bleeding
10/12/2016 30
Water drop-8, NGS. ©mohammad reza shojaee
Interpretation

31. #2:Concentration
In specialized unit for GIB management
within GASTROENTEROLOGY
1. an elderly patient
1. major comorbidities,
2. often taking a ‘blood thinner’
2. requiring limited transfusions
1. 5% require large volume transfusion
3. requiring radiology & endoscopy
4. not requiring urgent surgery
5. not having clinical diagnosis
10/12/2016 31
Water drop-4, NGS. ©mohammad reza shojaee
Interpretation

32. #3: Beauty of centralization
• Experience
• Regular and easy audits
• Reports to MD / CEO
• Easy leading: regionally & nationally
• Development of guidelines and pathways
and SOP afterwards
• Teaching / research
• Collaboration with DME
• Less biased communication
• Urgent or semi-urgent endoscopies
• Reduction of duplication of functions &
variations in care provision
• Better service at a lower cost
10/12/2016 32
Water drop-1, NGS. ©mohammad reza shojaee
Interpretation

33. Getting it right for every patient every time
MD bulletin, October 2016
Dr. Steve Evans, Medical Director
• The 1st paragraph is about the funding of health and social care …
• The 2nd paragraph: ‘For us in Liverpool this merely intensifies the pressures
we are all experiencing on a daily basis and increases the imperative for us
to find better ways of working collaboratively across our health system – our
Sustainability andTransformation Plan aims to reduce unnecessary
duplication and variation in clinical services, thereby providing a better
service for our patients at a lower cost.’
• AN EXCELLENTCHANCE to lead along the proper pathway
10/12/2016 33
Thank you