UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood

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 2008South West RTC

British Society of Gastroenterology


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


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



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?


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


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

• South West RTC = 594 cases


Participation


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 = 17 Organisational? No. of cases = 594 % regional total

A Yes 38 6

B Yes 42 7

C Yes 82 14

D Yes 34 6

F Yes - -

G Yes 18 3

H Yes 31 5

J Yes 42 7

K Yes 11 2

M Yes 30 5

N Yes 8 1

P Yes 57 10

Q Yes 17 3

R Yes 48 8

T Yes 38 6

V Yes 60 10

W Yes 38 6



Methodology AUDIT STANDARDS

PILOT

DATA COLLECTION

ANALYSIS

Clinical end-points

Service provision

All suspected AUGIB1/5/7- 30/6/7

Online data entryCEEU

+Steering group


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 - Organisation of care - UK


RESULTS Process of care: Admissions% admitted by Gastroenterology/GI bleeding team


0

5

10

15

20

25

30

35

Hospitals

%

5

1

51

9

2

722

1

1

1

2

3

5

45

11


Process of care: Admissions% admitted out of hours


0

10

20

30

40

50

60

70

80

90

100

UK A B C D F G H J K M N P Q R T V W

Hospitals

%

3973

1

17

2211

0

6

6

18

5

17

51

2425

21

27

2026


Process of care: Assessment % having risk assessment score calculated and recorded


0

10

20

30

40

50

60

70

80

90

100


Hospitals

%

1261

23

17

25

30

4

1 1

412

114

12

36

10

2


Process of care: Assessment % with initial Rockall score 3 or more at presentation


0

10

20

30

40

50

60

70

80

90

100

Hospitals

%3499 310 19

22

24

23

8

19 24

4

9

7

35

11

27 23

33

22


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 = 38%

0

10

20

30

40

50

60

70

Hospitals

% 2241

220

17

8

21

20

6

14 19

3

13

4

23

4

19 15 24

10



15% of RBC transfusions deemed inappropriate (Hb ≥10g/dL and haemodynamically stable)

3% received platelets – 42% deemed inappropriate

7% received FFP – 27% deemed inappropriate57% of patients with INR >1.5 did not get FFP

8% (473/6750) on warfarin87% of warfarin stopped50% received Vitamin K

Process of care: Transfusion – UK data


Process of care: Endoscopy% of patients having first endoscopy within 24 hours of presentation


0

10

20

30

40

50

60

70

80

Hospitals

%

2515/5004

241/348

22/36

8/1923/51

20/27

5/10 14/29

19/34

7/11

10/22

2/8

29/49

9/13

22/35

26/36

19/34

6/24


Process of care: Endoscopy% having first endoscopy out of hours


0

5

10

15

20

25

30

35

40

45


Hospitals

%

840/5004

10/36

8/19

12/51

5/27

3/10

1/29

9/34

1/11

3/22

2/8

10/49

1/13

8/35

3/36

7/24

3/24


Process of care: Endoscopic diagnoses % with endoscopic diagnosis of varices


0

2

4

6

8

10

12

14

16

18

20

Hospitals

%

544/5004

33/438

7/36

1/19

1/51

2/27

1/10

1/29

4/34

0/11 0/22

1/8

2/49

0/13

3/35

4/36

6/34

0/24


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

0

10

20

30

40

50

60

70

80

Hospitals

%

1826/5004

162/438

12/36

7/19

13/51

15/27

2/10

20/29

12/34

6/11

5/22

0/8

18/49

6/13

12/35

14/36 13/34

7/24


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% receiving endoscopic therapy for oesophageal varices at first endoscopy


0

10

20

30

40

50

60

70

80

90

100

Hospitals

%

335/517

16/26

1/4

0/1

1/3

0/1

2/3

3/5

1/1 1/11/12/2 4/4


Process of care: Endoscopy% receiving endoscopic therapy for actively bleeding ulcer at first endoscopy


0

10

20

30

40

50

60

70

80

90

100

Hospitals

%

598/78957/77

5/6

2/4

7/9 4/5

4/7

7/9

2/2

2/3

8/10

1/3

3/4

7/7

4/7

1/1


Process of care: Endoscopy% receiving endoscopic therapy for non-bleeding visible vessel at first endoscopy


0

10

20

30

40

50

60

70

80

90

100

Hospitals

%

292/318

30/32

2/2 2/21/11/12/25/51/11/13/33/31/11/1 1/1

6/8


Process of care: Therapy after endoscopy% receiving iv PPI after endoscopic therapy to peptic ulcer


0

10

20

30

40

50

60

70

80

90

100


Hospitals

%

460/656

4/5

2/2 7/7 7/73/31/12/2 1/1

2/4

0/4

3/7

0/4

4/8 2/4


Process of care: Diagnoses


Endoscopic finding %

Oesophagitis 24

Gastritis/ erosions 22

Ulcer 36

Erosive duodenitis 13

Malignancy 4

Mallory- Weiss 4

Varices 11

Portal Gastropathy 5

Vascular malformation 3

None 17

6%1993

32%SRH


Process of care: Risk assessment% with final Rockall score 6 or more


0

5

10

15

20

25

30

35

40

45

Hospitals

%

1377

131

12

5

9

11

9

14

3

5

3

15

5

9

14

8

9


Process of care: Outcomes% discharged within 7 days of presentation


0

10

20

30

40

50

60

70

80

90

100

Hospitals

%

3906 397

25

26

63 27

15

16

25

11

13

37

13

30

29

42 25


Process of care: Outcomes% mortality, % alive in hospital at 28 days, and % discharged within 28 days – for all patients


0%

20%

40%

60%

80%

100%

A B C D F G H J K M N P Q R T V W

Discharged within 28 days Alive in Hospital at 28 days Died

4 4 9 2

5 3 5 2 1

2 3 3 4 7 7

6

3

6

3

6

4

10 3 3

1

1

1

9

2845 33 37 11 46

2

19 936 25 17 2974 26 32

2

6


Risk standardised mortality ratio Acute Upper Gastrointestinal Bleeding (AUGIB)

Process of care: OutcomesHospital RSMR 95% CI

A 1.25 0.03 to 2.48

B 1.33 0.34 to 2.32

C 0.86 0.22 to 1.49

D 0.89 0.02 to 1.75

G 0.00

H 0.94 -0.12 to 2.01

J 0.64 -0.08 to 1.36

K 2.51 -0.97 to 5.98

M 0.33 -0.32 to 0.99

N 3.01 -1.16 to 7.18

P 0.91 0.11 to 1.70

Q 1.90 -0.25 to 4.05

R 0.85 0.10 to 1.59

T 0.58 -0.22 to 1.38

V 1.22 0.42 to 2.02

W 0.97 0.02 to 1.91


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%


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


ConclusionsAcute 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


Acknowledgements


• Hospital staff who collected the audit data

• Project team: Dr Sarah HearnshawMr John Grant-CaseyMr Derek LoweProf Richard LoganProf Tim RockallDr Simon TravisProf Mike MurphyDr Kel Palmer


UK Comparative Audit of Upper Gastrointestinal Bleeding

and the Use of Blood

Prepared by John Grant-Casey & Sarah Hearnshaw

April 2008South West RTC

British Society of Gastroenterology

Documents

UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood