John Grant-Casey & Sarah Hearnshaw British Society of Gastroenterology UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood This set of slides presents the main findings from the audit and gives comparable data for hospitals in North 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. . Prepared by John Grant-Casey & Sarah Hearnshaw North West RTC April 2008

The National Comparative Audit Programme Background information 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 This slide describes the National Comparative Audit programme

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

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?

What were the audit aims? Acute Upper Gastrointestinal Bleeding (AUGIB) What were the audit aims? 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 This slide sets out what we hoped to achieve by conducting the audit.

217 (84%) hospitals sent any information Acute Upper Gastrointestinal Bleeding (AUGIB) Participation 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 North West RTC =890 cases

Data from 217 hospitals (84%) 8939 cases submitted 1090 insufficient data 1099 not AUGIB 6750 analysed 82% new admissions 18% inpatients

Participation Hospital Code n = 29 Organisational? No. of cases = 890 % regional total A Yes 47 5 B 78 9 C 45 D 20 2 E 34 4 F No G 37 H 23 3 J 12 1 K 19 L 31 M N 29

Participation (Continued) Hospital Code n = 29 Organisational? No. of cases = 890 % regional total P Yes 46 5 Q 36 4 R 66 7 S 19 2 T 35 V 45 W 37 X 38 Y 1 Z AA 24 3 AB AC 16 AD 22 AE 43 AF No 39

AUDIT STANDARDS PILOT DATA COLLECTION ANALYSIS Clinical end-points Acute Upper Gastrointestinal Bleeding (AUGIB) AUDIT STANDARDS PILOT DATA COLLECTION ANALYSIS Methodology Clinical end-points Service provision All suspected AUGIB 1/5/7- 30/6/7 Online data entry CEEU + Steering group

Acute Upper Gastrointestinal Bleeding (AUGIB) RESULTS - Organisation of care - UK 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

RESULTS Process of care: Admissions Acute Upper Gastrointestinal Bleeding (AUGIB) RESULTS Process of care: Admissions % admitted by Gastroenterology/GI bleeding team

Process of care: Admissions Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Admissions % admitted out of hours

Process of care: Assessment Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Assessment % having risk assessment score calculated and recorded

Process of care: Assessment Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Assessment % with initial Rockall score 3 or more at presentation

Process of care: Transfusion Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Transfusion % patients transfused with RBC as part of initial resuscitation In the UK 33% of patients received a red blood cell transfusion. Regional average = 31%

Process of care: Transfusion – UK data Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Transfusion – UK data 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: Endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopy % of patients having first endoscopy within 24 hours of presentation

Process of care: Endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopy % having first endoscopy out of hours

Process of care: Endoscopic diagnoses Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopic diagnoses % with endoscopic diagnosis of varices

Process of care: Endoscopic diagnoses Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopic diagnoses % with endoscopic diagnosis of PUD

Process of care: Endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopy 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

Process of care: Endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopy % receiving endoscopic therapy for oesophageal varices at first endoscopy

Process of care: Endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopy % receiving endoscopic therapy for actively bleeding ulcer at first endoscopy

Process of care: Endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopy % receiving endoscopic therapy for non-bleeding visible vessel at first endoscopy

Process of care: Therapy after endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Therapy after endoscopy % receiving iv PPI after endoscopic therapy to peptic ulcer

Process of care: Diagnoses Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Diagnoses Endoscopic finding % Oesophagitis 24 Gastritis/ erosions 22 Ulcer 36 Erosive duodenitis 13 Malignancy 4 Mallory- Weiss Varices 11 Portal Gastropathy 5 Vascular malformation 3 None 17 32% SRH 6% 1993

Process of care: Risk assessment Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Risk assessment % with final Rockall score 6 or more

Process of care: Outcomes Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Outcomes % discharged within 7 days of presentation

Process of care: Outcomes Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Outcomes % mortality, % alive in hospital at 28 days, and % discharged within 28 days – for all patients

Process of care: Outcomes – slide 1 Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Outcomes – slide 1 Risk standardised mortality ratio Hospital RSMR 95% CI A 1.02 0.13 to 1.91 B 0.61 0.08 to 1.14 C 0.57 -0.07 to 1.21 D 0.82 -0.11 to 1.75 E 0.63 -0.60 to 1.87 G 1.57 0.19 to 2.94 H 0.84 -0.32 to 1.99 J 0.79 -0.10 to 1.67 K 1.21 -0.47 to 2.89 L 0.00   M 0.38 -0.36 to 1.12 N 0.75 -0.10 to 1.60 P Q 1.58 0.03 to 3.12 R 2.14 0.74 to 3.53

Process of care: Outcomes – slide 2 Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Outcomes – slide 2 Risk standardised mortality ratio Hospital RSMR 95% CI S 1.48 0.18 to 2.78 T 0.33 -0.13 to 0.79 V 0.61 -0.59 to 1.82 W 1.90 0.38 to 3.41 X 0.76 0.02 to 1.50 Y 0.67 -0.09 to 1.42 Z 1.06 0.02 to 2.10 AA   AB 1.17 -0.45 to 2.80 AC 0.59 -.057 to 1.76 AD 1.60 -1.54 to 4.74 AE 0.00 AF 2.67 0.53 to 4.81 AG 1.62 0.20 to 3.05 AH 0.71 -0.09 to 1.51

Service provision and outcomes Acute Upper Gastrointestinal Bleeding (AUGIB) Service provision and outcomes OOH on call rota (3499) No OOH rota (2821) 1st Endoscopy OOH 586/2969 (20%) 254/1980 (13%) Re-bleeding rate 14% 13% Median stay 6 days 5 days Mortality after OGD 7.1% 8.2%

Variation in case identification – selection bias Acute Upper Gastrointestinal Bleeding (AUGIB) Discussion 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

Largest ever audit of AUGIB in UK Acute Upper Gastrointestinal Bleeding (AUGIB) Conclusions 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

Hospital staff who collected the audit data 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 Acknowledgements

John Grant-Casey & Sarah Hearnshaw British Society of Gastroenterology UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood . Prepared by John Grant-Casey & Sarah Hearnshaw North West RTC April 2008