British Society of
Gastroenterology
UK Comparative Audit of Upper
Gastrointestinal Bleeding
and the Use of Blood
North West RTC
National Comparative Audit of Blood Transfusion
Prepared by
John Grant-Casey &
Sarah Hearnshaw
April 2008
National Blood Service
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
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
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?
National Comparative Audit of Blood Transfusion
National Blood Service
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 (riskassessment) score
Work with hospitals and stakeholders to reduce
variation in care, and improve outcomes
National Comparative Audit of Blood Transfusion
National Blood Service
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
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
National Comparative Audit of Blood Transfusion
18% inpatients
National Blood Service
Participation
Hospital Code n = 29
Organisational?
No. of cases = 890
% regional total
A
Yes
47
5
B
Yes
78
9
C
Yes
45
5
D
Yes
20
2
E
Yes
34
4
F
No
20
2
G
Yes
37
4
H
Yes
23
3
J
Yes
12
1
K
Yes
19
2
L
Yes
31
3
M
No
1
1
N
Yes
29
3
National Comparative Audit of Blood Transfusion
National Blood Service
Participation (Continued)
Hospital Code n = 29
Organisational?
No. of cases = 890
% regional total
P
Yes
46
5
Q
Yes
36
4
R
Yes
66
7
S
Yes
19
2
T
Yes
35
4
V
Yes
45
5
W
Yes
37
4
X
Yes
38
4
Y
Yes
4
1
Z
Yes
19
2
AA
Yes
24
3
AB
Yes
5
1
AC
Yes
16
2
AD
Yes
22
2
AE
Yes
43
5
AF
No
39
4
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Methodology
AUDIT STANDARDS
Clinical end-points
PILOT
Service provision
DATA COLLECTION
All suspected AUGIB
1/5/7- 30/6/7
Online data entry
ANALYSIS
National Comparative Audit of Blood Transfusion
CEEU
+
Steering group
National Blood Service
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
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
RESULTS Process of care: Admissions
% admitted by Gastroenterology/GI bleeding team
40
35
30
25
%
20
15
10
5
AH
AF
AG
AE
AD
AC
AB
AA
Z
Y
X
W
V
T
S
R
Q
N
M
L
K
J
H
G
F
E
D
C
B
A
P
Hospitals
R
U
eg K
io
na
l
0
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Admissions
% admitted out of hours
90
80
70
60
50
%
40
30
20
10
0
UK
A
B
C
D
E
F
G
H
J
K
L
M
N
P
Q
R
S
T
V
W
X
Y
Z
AA AB AC AD AE AF AG AH
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Assessment
% having risk assessment score calculated and recorded
100
90
80
70
60
%
50
40
30
20
10
0
UK
A
B
C
D
E
F
G
H
J
K
L
M
N
P
Q
R
S
T
V
W
X
Y
Z
AA AB AC AD AE AF AG AH
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Assessment
% with initial Rockall score 3 or more at presentation
90
80
70
60
50
%
40
30
20
10
A
H
A
F
A
G
A
E
A
D
A
C
A
B
A
A
Z
Y
X
W
V
T
S
R
Q
N
M
L
K
J
H
G
F
E
D
C
B
A
P
Hospitals
R
U
eg K
io
na
l
0
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Transfusion
% patients transfused with RBC as part of initial resuscitation
70
60
50
40
%
30
20
10
A
H
A
F
A
G
A
E
A
D
A
C
A
B
Z
A
A
Y
X
W
V
T
S
R
Q
N
M
L
K
J
H
G
F
E
D
C
B
A
P
Hospitals
R
U
eg K
io
na
l
0
In the UK 33% of patients received a red blood cell transfusion. Regional average = 31%
National Comparative Audit of Blood Transfusion
National Blood Service
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
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Endoscopy
% of patients having first endoscopy within 24 hours of presentation
90
80
70
60
50
%
40
30
20
10
AH
AF
AG
AE
AD
AC
AB
Z
AA
Y
X
W
V
T
S
R
Q
N
M
L
K
J
H
G
F
E
D
C
B
A
P
Hospitals
R
U
eg K
io
na
l
0
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Endoscopy
% having first endoscopy out of hours
40
35
30
25
%
20
15
10
5
0
UK
A
B
C
D
E
F
G
H
J
K
L
M
N
P
Q
R
S
T
V
W
X
Y
Z
AA AB AC AD AE AF AG AH
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Endoscopic diagnoses
% with endoscopic diagnosis of varices
50
45
40
35
30
%
25
20
15
10
5
A
H
A
F
A
G
A
E
A
D
A
C
A
B
A
A
Z
Y
X
W
V
T
S
R
Q
N
M
L
K
J
H
G
F
E
D
C
B
A
P
Hospitals
R
U
eg K
io
na
l
0
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Endoscopic diagnoses
% with endoscopic diagnosis of PUD
100
90
80
70
60
%
50
40
30
20
10
A
H
A
F
A
G
A
E
A
D
A
B
A
C
Z
A
A
Y
X
W
V
T
S
R
Q
P
N
M
L
K
J
H
G
F
E
D
C
B
A
R UK
eg
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
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
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Endoscopy
% receiving endoscopic therapy for oesophageal varices at first endoscopy
100
90
80
70
60
%
50
40
30
20
10
A
H
A
F
A
G
A
E
A
D
A
C
A
B
A
A
Z
Y
X
W
V
T
S
R
Q
P
M
L
K
J
H
G
F
E
D
C
B
A
N
Hospitals
R
U
eg K
io
na
l
0
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Endoscopy
% receiving endoscopic therapy for actively bleeding ulcer at first endoscopy
100
90
80
70
60
%
50
40
30
20
10
A
H
A
F
A
G
A
E
A
D
A
B
A
C
A
A
Z
Y
X
W
V
T
S
R
Q
N
M
L
K
J
H
G
F
E
D
C
B
A
P
Hospitals
R
U
eg K
io
na
l
0
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Endoscopy
% receiving endoscopic therapy for non-bleeding visible vessel at first endoscopy
100
90
80
70
60
%
50
40
30
20
10
R
A
H
A
F
A
G
A
E
A
D
A
C
A
B
A
A
Z
Y
X
W
V
T
S
R
Q
P
N
M
L
K
J
H
G
F
E
D
C
B
A
U
eg K
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Therapy after endoscopy
% receiving iv PPI after endoscopic therapy to peptic ulcer
100
90
80
70
60
%
50
40
30
20
10
0
UK
A
B
C
D
E
F
G
H
J
K
L
M
N
P
Q
R
S
T
V
W
X
Y
Z
AA AB AC AD AE AF AG AH
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Diagnoses
Endoscopic finding
Oesophagitis
%
24
Gastritis/ erosions
Ulcer
Erosive duodenitis
22
36
13
Malignancy
Mallory- Weiss
Varices
Portal Gastropathy
4
4
11
5
Vascular malformation
None
3
17
National Comparative Audit of Blood Transfusion
32%
SRH
6%
1993
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Risk assessment
% with final Rockall score 6 or more
40
35
30
25
%
20
15
10
5
R
A
H
A
F
A
G
A
E
A
D
A
C
A
B
A
A
Z
Y
X
W
V
T
S
R
Q
P
N
M
L
K
J
H
G
F
E
D
C
B
A
U
eg K
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Outcomes
% discharged within 7 days of presentation
90
80
70
60
50
%
40
30
20
10
R
A
H
A
F
A
G
A
E
A
D
A
C
A
B
A
A
Z
Y
X
W
V
T
S
R
Q
P
N
M
L
K
J
H
G
F
E
D
C
B
A
U
eg K
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Outcomes
% mortality, % alive in hospital at 28 days, and % discharged within 28 days – for all patients
100%
80%
60%
40%
20%
0%
A
B
C
D
E
F
G
H
J
K
L
M
N
P
Q
Discharged within 28 days
National Comparative Audit of Blood Transfusion
R
S
T
V
W
X
Alive in Hospital at 28 days
Y
Z
AA AB AC AD AE AF AG AH
Died
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Risk standardised mortality ratio
Process of care: Outcomes – slide 1
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
0.00
Q
1.58
0.03 to 3.12
R
2.14
0.74 to 3.53
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Risk standardised mortality ratio
Process of care: Outcomes – slide 2
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
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
AA
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Service provision and outcomes
1st Endoscopy
OOH
Re-bleeding rate
Median stay
Mortality after OGD
OOH on call rota
(3499)
No OOH rota
(2821)
586/2969
(20%)
14%
254/1980
(13%)
13%
6 days
5 days
7.1%
8.2%
National Comparative Audit of Blood Transfusion
National Blood Service
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
National Comparative Audit of Blood Transfusion
National Blood Service
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
National Comparative Audit of Blood Transfusion
National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)
Acknowledgements
• 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
National Comparative Audit of Blood Transfusion
National Blood Service
British Society of
Gastroenterology
UK Comparative Audit of Upper
Gastrointestinal Bleeding
and the Use of Blood
North West RTC
National Comparative Audit of Blood Transfusion
Prepared by
John Grant-Casey &
Sarah Hearnshaw
April 2008
National Blood Service