1. National Comparative Audit of Blood Transfusion National Blood Service UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood Prepared by John Grant-Casey & Sarah Hearnshaw April 2008 East Midlands RTC British Society of Gastroenterology

2. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service 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 East Midlands RTC = 380 cases Acute Upper Gastrointestinal Bleeding (AUGIB) Participation

7. National Comparative Audit of Blood Transfusion National Blood Service Data from 217 hospitals (84%) 8939 cases submitted 1090 insufficient data 1099 not AUGIB 6750 analysed 82% new admissions 18% inpatients

8. National Comparative Audit of Blood Transfusion National Blood Service Participation Hospital Code (N=12) Organisational?No. of cases 380 % regional total AYes4011 BYes5916 CYes72 D 00 E 318 FYes4011 GYes4512 HYes339 JYes298 KYes164 LYes4512 MYes359

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

10. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service RESULTS Process of care: Admissions % admitted by Gastroenterology/GI bleeding team Acute Upper Gastrointestinal Bleeding (AUGIB)

12. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Admissions % admitted out of hours Acute Upper Gastrointestinal Bleeding (AUGIB)

13. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Assessment % having risk assessment score calculated and recorded Acute Upper Gastrointestinal Bleeding (AUGIB)

14. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Assessment % with initial Rockall score 3 or more at presentation Acute Upper Gastrointestinal Bleeding (AUGIB)

15. National Comparative Audit of Blood Transfusion National Blood Service 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 = 33%

16. National Comparative Audit of Blood Transfusion National Blood Service Acute Upper Gastrointestinal Bleeding (AUGIB) 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

17. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Endoscopy % of patients having first endoscopy within 24 hours of presentation Acute Upper Gastrointestinal Bleeding (AUGIB)

18. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Endoscopy % having first endoscopy out of hours Acute Upper Gastrointestinal Bleeding (AUGIB)

19. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Endoscopic diagnoses % with endoscopic diagnosis of varices Acute Upper Gastrointestinal Bleeding (AUGIB)

20. National Comparative Audit of Blood Transfusion National Blood Service Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Endoscopic diagnoses % with endoscopic diagnosis of PUD

21. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Endoscopy % receiving endoscopic therapy for oesophageal varices at first endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB)

23. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Endoscopy % receiving endoscopic therapy for actively bleeding ulcer at first endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB)

24. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Endoscopy % receiving endoscopic therapy for non-bleeding visible vessel at first endoscopy Acute Upper Gastrointestinal Bleeding (AUGIB)

25. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Therapy after endoscopy % receiving iv PPI after endoscopic therapy to peptic ulcer Acute Upper Gastrointestinal Bleeding (AUGIB)

26. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Diagnoses Acute Upper Gastrointestinal Bleeding (AUGIB) Endoscopic finding% Oesophagitis24 Gastritis/ erosions22 Ulcer36 Erosive duodenitis13 Malignancy4 Mallory- Weiss4 Varices11 Portal Gastropathy5 Vascular malformation3 None17 6% 1993 32% SRH

27. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Risk assessment % with final Rockall score 6 or more Acute Upper Gastrointestinal Bleeding (AUGIB)

28. National Comparative Audit of Blood Transfusion National Blood Service Process of care: Outcomes % discharged within 7 days of presentation Acute Upper Gastrointestinal Bleeding (AUGIB)

29. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service Risk standardised mortality ratio Acute Upper Gastrointestinal Bleeding (AUGIB) Process of care: Outcomes HospitalRSMR95% CI A0.25-0.24 to 0.75 B0.570.01 to 1.13 C0.00- D-- E1.230.02 to 2.44 F1.290.33 to 2.25 G0.27-0.26 to 0.80 H0.61-0.23 to 1.45 J0.36-0.35 to 1.07 K3.410.68 to 6.14 L1.130.14 to 2.13 M0.76-0.10 to 1.63

31. National Comparative Audit of Blood Transfusion National Blood Service Service provision and outcomes Acute Upper Gastrointestinal Bleeding (AUGIB) OOH on call rota (3499) No OOH rota (2821) 1 st Endoscopy OOH 586/2969 (20%) 254/1980 (13%) Re-bleeding rate14%13% Median stay6 days5 days Mortality after OGD7.1%8.2%

32. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service 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. National Comparative Audit of Blood Transfusion National Blood Service UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood Prepared by John Grant-Casey & Sarah Hearnshaw April 2008 East Midlands RTC British Society of Gastroenterology