National Comparative Audit
of Blood Transfusion
UK Comparative Audit of Upper Gastrointestinal Bleeding
and the Use of Blood
Background
This audit is the next UK comparative audit from NHSBT of the use of blood following
the audits of orthopaedic surgery and platelet transfusions in 2006. Most local and
regional audits of the use of blood have been in surgical patients. Recent efforts to
promote the appropriate use of blood have resulted in a substantial reduction in blood
use in surgical patients. More than 60% of red cells are now used in medical
patients. Patients with upper gastrointestinal (GI) bleeding are one of the leading
medical patient groups using blood.
Previous large regional audits of upper GI bleeding
A major audit of gastrointestinal bleeding took place in the early 1990s on behalf of
the Royal College of Surgeons of England and led to an important series of papers by
Tim Rockall et al. (BMJ 1995; 311: 222-6; Gut 1997; 41: 606-611; The Lancet 1996;
347: 1138-1140).
One of the most important findings of the Rockall audit was hospital mortality of 14%
in patients admitted with gastrointestinal bleeding, rising to more than 30% in patients
who bled whilst in-patients. Rockall subsequently developed a risk stratification score
which proved to be robust and to have practical, clinical advantages. The use of
blood products in the management and risk stratification of patients with upper
gastrointestinal haemorrhage has not previously been systematically evaluated.
Thus we believe that the time is now ripe for a re-audit of acute upper gastrointestinal
bleeding, specifically addressing risk stratification and the use of blood products. The
NHSBT and the BSG are undertaking this as a joint collaboration.
This audit
Comparative audit involves collection of organisational and individual patient data
from hospitals, with feedback of the results so sites can compare their practice with
others. This is linked with strategies for improvement in practice involving education
and the development of achievable benchmarks. In other areas of medicine,
clinicians and hospital managers have found the comparative data presented in this
way to be sufficiently persuasive to justify introducing change locally. Previous audits
headed by the Royal College of Physicians have been successful in demonstrating
improvements in practice through the use of comparative audit in areas such as
myocardial infarction and stroke. There is every reason to believe that this audit of
gastrointestinal bleeding, as a collaboration between UK hospitals, the NHSBT, the
RCP and the BSG, can have similar positive effects upon performance.
Audit questions
 Are patients with upper GI bleeding in UK hospitals managed according to
published guidelines?
 What is the outcome for patients admitted to hospital with upper GI bleeding or
who bleed during hospitalisation for other reasons?
 Is blood product use appropriate?
Mechanism of data collection
Previous national blood transfusion audits have been very successful with a high
uptake by hospitals and important recommendations have followed. Their success is
in part due to the identification of suitable audit leads to manage and run the audit
locally. The success of this audit depends upon participating hospitals identifying an
audit lead (and assistant staff) who will spend a few hours collecting and returning
data. Participating hospitals will contribute data for the audit via internet-based audit
tools. This will become available from 1st May 2007 via
http://www.blood.co.uk/hospitals/safe_use/clinical_audit/National_Comparative/index.asp
Identifying an audit lead
We anticipate the audit leads will predominantly be gastroenterology Specialist
Registrars, supported by a Consultant Gastroenterologist, although they may be from
any discipline (such as Haematology and blood transfusion, acute general medicine,
or a member of the hospital audit department). The task is for 3 months: 1 May – 31
June 2007 for case identification and until 1st August for data entry. The audit lead
will be given a unique code which he or she will use to enter individual patient data,
but that can be shared with other staff in the hospital, such as ward, endoscopy or
A&E staff, to assist with data entry. The audit lead will be the point of contact for the
project team, and will be responsible for ensuring complete and accurate data
collection.
Each site also needs to identify one or more members of staff to be responsible for
case identification. This is a key role and will involve for daily searching of
admissions books in admitting wards, as well as liaising with gastroenterology and
medical registrars and endoscopy units to identify every patient with a suspected (or
confirmed) upper gastrointestinal bleed. (Full guidance will be given as to how to
identify cases). The case identifiers in each site will enter on to the web tool the
admission details of the potential cases, and will give every case a unique identifier.
The audit lead will then be given the details of the identified cases, and will be
responsible for deciding whether full case data needs entering. Reasons for not
entering the full data will be required (e.g. haemoptysis not haematemesis at
presentation), and must be entered on the web tool. The audit lead will then enter
the full data for all appropriate cases. We expect each case to take around 30
minutes to complete using the online web-tool. Help boxes will be supplied for every
audit question, and support will be available throughout the data collection period by
e-mail and telephone, for both the case identifiers and the audit lead.
We recommend that the clinical lead for endoscopy in each participating hospital
works closely with and provides support to the nominated audit lead.
The clinical lead for endoscopy, the audit lead and the case identifier will be listed as
contributors in the audit report. The audit lead and case identifiers will also be able to
cite this study on their curriculum vitae as a recognised participation in UK audit.
Operating the audit
All patients with a suspected upper gastrointestinal bleed will be identified for a period
of two months from 1st May until 31st June 2007. Each hospital will collect and enter
data on those identified until patient death in hospital, hospital discharge or until the
patient has been in hospital more than 28 days following their upper GI bleed. (This
means some patient data will be collected and entered after the recruitment periods,
if the patient is still in hospital). Data must be entered in full by 1st August 2007.
The clinical lead for endoscopy will be asked to complete a short organisational audit
tool.
After the audit
The audit will report its findings by December 2007, and each hospital will receive a
written report that will allow it to compare its own practice with that of other
participating hospitals.
Hospitals will be able to access their raw data during and after the audit data
collection period, enabling them to conduct their own local analysis should they wish.
Participating hospitals will be offered a Microsoft PowerPoint slide show that will
illustrate the main findings of the audit, and will allow comparison of the practice of
individual hospitals against their regional peers, as well as against the national
picture. The audit leads are encouraged to present their individual audit results
locally.
It is anticipated that the National Comparative Audit of Blood Transfusion will make
presentations on the audit findings in a number of venues and take every opportunity
to stimulate discussion on the use of blood in this clinical area.
Data to be collected from patient’s casenotes & hospital IT systems:
 Admission date, time, clinical area, and admitting team, referral patterns (e.g. to
Gastroenterology / Surgery)
 Patient age and gender
 Clinical presentation (with bleed whether new admission or in-patient),
observations, initial blood tests and results, drug history, co-morbidities,
 Endoscopy date and time, endoscopist grade, endoscopic findings, endoscopic
therapies (for all endoscopies), control of bleeding, further bleeding
 Specific questions re: variceal bleeds – use of albumin, specific drug and
endoscopic therapies, referral to specialist units
 Initial drug therapy, total blood product use, subsequent drug therapies
 Radiological and surgical intervention (with details of dates / times / grade of
surgeon, procedures performed, surgical complications)
 Outcomes – final diagnosis, discharge dates, in-patient deaths and cause of
death.
Contact details
For further information and to answer any questions about the audit, please contact
the audit project team.
Project Manager
Research Fellow
Project Officer
Mr John Grant-Casey
John.Grant-Casey@nbs.nhs.uk
Tel: 01865 440046
Dr Sarah Hearnshaw
Sarah.Hearnshaw@nbs.nhs.uk
Tel 01865 447743
Mr David Dalton
David.Dalton@nbs.nhs.uk
Tel 0121 2538216