Journal Article

Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit

Hearnshaw, Sarah A, Palmer, Kelvin R, Travis, Simon P L, Lowe, Derek, Logan, Richard F A, Murphy, Mike F

2010

Overview

ObjectivesTo examine the use of endoscopy in the UK for acute upper gastrointestinal bleeding (AUGIB) and compare with published standards.To assess the organisation of endoscopy services for AUGIB in the UK.To examine the relationship between outcomes and out of hours (OOH) service provision.DesignMulti-centre cross sectional clinical audit.SettingAll UK hospitals accepting admissions with AUGIB.PatientsAll adults (≥16 yrs) presenting with AUGIB between 1st May and 30th June 2007.Data CollectionA custom designed web-based reporting tool was used to collect data on patient characteristics, comorbidity and haemodynamic status at presentation to calculate the Rockall score, use and timing of endoscopy, treatment including endoscopic, rebleeding and in-hospital mortality. A mailed questionnaire was used to collect data on facilities and service organisation.ResultsData on 6750 patients (median age 68 years) were analysed from 208 hospitals. 74% underwent inpatient endoscopy; of these 50% took place within 24 h of presentation, 82% during normal working hours and 3% between midnight and 8 am. Of patients deemed high-risk (pre-endoscopy Rockall score ≥5) only 55% were endoscoped within 24 h and 14% waited ≥72 h for endoscopy. Lesions with a high risk of rebleeding were present in 28% of patients of whom 74% received endoscopic therapy. Further bleeding was evident in 13% and mortality in those endoscoped was 7.4% (95% CI 6.7% to 8.1%). In 52% of hospitals a consultant led out of hours (OOH) endoscopy rota existed; in these hospitals 20% of first endoscopies were performed OOH compared with 13% in those with no OOH rota and endoscopic therapy was more likely to be administered (25% vs 21% in hospitals with no OOH rota). The risk adjusted mortality ratio was higher (1.21, p=0.10, (95%CI 0.96 to 1.51)) in hospitals without such rotas.ConclusionsThis audit has found continuing delays in performing endoscopy after AUGIB and underutilisation of standard endoscopic therapy particularly for variceal bleeding. In hospitals with a formal OOH endoscopy rota patients received earlier endoscopy, were more likely to receive endoscopic therapy and may have a lower mortality.

• Publisher: BMJ Publishing Group Ltd and British Society of Gastroenterology,BMJ Publishing Group,BMJ Publishing Group LTD
• Subject: Acute Disease / Adult / After-Hours Care - organization & administration / Aged / Aged, 80 and over / Audits / Biological and medical sciences / Blood transfusions / Conscious Sedation - methods / Data collection / Emergencies / emergency medical services / endoscopic procedures / Endoscopy / Epidemiologic Methods / Female / Gastroenterology / Gastroenterology. Liver. Pancreas. Abdomen / gastrointestinal / gastrointestinal haemorrhage / Gastrointestinal Hemorrhage - etiology / Gastrointestinal Hemorrhage - mortality / Gastrointestinal Hemorrhage - therapy / Gastroscopy - utilization / Humans / Laboratories / Male / Medical sciences / Middle Aged / Mortality / Other diseases. Semiology / Proton Pump Inhibitors - therapeutic use / Questionnaires / Recurrence / Stomach. Duodenum. Small intestine. Colon. Rectum. Anus / Studies / Surgery / Time Factors / Treatment Outcome / Ulcers / United Kingdom - epidemiology