south west rtc
TRANSCRIPT
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
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
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
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
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
• South West RTC = 594 cases
Acute Upper Gastrointestinal Bleeding (AUGIB)
Participation
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
National Comparative Audit of Blood Transfusion National Blood Service
Participation
634YesD
--YesF
318YesG
531YesH
742YesJ
211YesK
638YesW
1060YesV
638YesT
848YesR
317YesQ
1057YesP
18YesN
530YesM
1482YesC
742YesB
638YesA
% regional totalNo. of cases = 594Organisational?Hospital Code n = 17
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 AUGIB1/5/7- 30/6/7
Online data entryCEEU
+Steering group
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
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)
0
5
10
15
20
25
30
35
UK
Reg
iona
lA B C D F G H J K M N P Q R T V W
Hospitals
%
5
1
51
9
2
722
1
1
1
2
3
5
45
11
National Comparative Audit of Blood Transfusion National Blood Service
Process of care: Admissions% admitted out of hours
Acute Upper Gastrointestinal Bleeding (AUGIB)
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
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)
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
%
1261
23
17
25
30
4
1 1
412
114
12
36
10
2
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)
0
10
20
30
40
50
60
70
80
90
100
UK
Reg
iona
lA B C D F G H J K M N P Q R T V W
Hospitals
%3499 310 19
22
24
23
8
19 24
4
9
7
35
11
27 23
33
22
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 = 38%
0
10
20
30
40
50
60
70
UK
Reg
iona
lA B C D F G H J K M N P Q R T V W
Hospitals
% 2241
220
17
8
21
20
6
14 19
3
13
4
23
4
19 15 24
10
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 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
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)
0
10
20
30
40
50
60
70
80
UK
Reg
iona
lA B C D F G H J K M N P Q R T V W
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
National Comparative Audit of Blood Transfusion National Blood Service
Process of care: Endoscopy% having first endoscopy out of hours
Acute Upper Gastrointestinal Bleeding (AUGIB)
0
5
10
15
20
25
30
35
40
45
UK A B C D F G H J K M N P Q R T V W
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
National Comparative Audit of Blood Transfusion National Blood Service
Process of care: Endoscopic diagnoses % with endoscopic diagnosis of varices
Acute Upper Gastrointestinal Bleeding (AUGIB)
0
2
4
6
8
10
12
14
16
18
20
UK
Reg
iona
l A B C D F G H J K M N P Q R T V W
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
National Comparative Audit of Blood Transfusion National Blood Service
Acute Upper Gastrointestinal Bleeding (AUGIB)Process of care: Endoscopic diagnoses % with endoscopic diagnosis of PUD
0
10
20
30
40
50
60
70
80
UK
Reg
iona
l A B C D F G H J K M N P Q R T V W
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
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
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)
0
10
20
30
40
50
60
70
80
90
100
UK
Reg
iona
l A B C D F G H J K M N P Q R T V W
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
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)
0
10
20
30
40
50
60
70
80
90
100
UK
Reg
iona
l A B C D F G H J K M N P Q R T V W
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
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)
0
10
20
30
40
50
60
70
80
90
100
UK
Reg
iona
l A B C D F G H J K M N P Q R T V W
Hospitals
%
292/318
30/32
2/2 2/21/11/12/25/51/11/13/33/31/11/1 1/1
6/8
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)
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
%
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
National Comparative Audit of Blood Transfusion National Blood Service
Process of care: Diagnoses
Acute Upper Gastrointestinal Bleeding (AUGIB)
17None
3Vascular malformation
5Portal Gastropathy
11Varices
4Mallory- Weiss
4Malignancy
13Erosive duodenitis
36Ulcer
22Gastritis/ erosions
24Oesophagitis
%Endoscopic finding
6%1993
32%SRH
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)
0
5
10
15
20
25
30
35
40
45
UK
Reg
iona
lA B C D F G H J K M N P Q R T V W
Hospitals
%
1377
131
12
5
9
11
9
14
3
5
3
15
5
9
14
8
9
National Comparative Audit of Blood Transfusion National Blood Service
Process of care: Outcomes% discharged within 7 days of presentation
Acute Upper Gastrointestinal Bleeding (AUGIB)
0
10
20
30
40
50
60
70
80
90
100
UK
Reg
iona
lA B C D F G H J K M N P Q R T V W
Hospitals
%
3906 397
25
26
63 27
15
16
25
11
13
37
13
30
29
42 25
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)
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
National Comparative Audit of Blood Transfusion National Blood Service
Risk standardised mortality ratio Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Outcomes
0.02 to 1.910.97W
0.42 to 2.021.22V
-0.22 to 1.380.58T
0.10 to 1.590.85R
-0.25 to 4.051.90Q
0.11 to 1.700.91P
-1.16 to 7.183.01N
-0.32 to 0.990.33M
-0.97 to 5.982.51K
-0.08 to 1.360.64J
-0.12 to 2.010.94H
0.00G
0.02 to 1.750.89D
0.22 to 1.490.86C
0.34 to 2.321.33B
0.03 to 2.481.25A
95% CIRSMRHospital
National Comparative Audit of Blood Transfusion National Blood Service
Service provision and outcomes
Acute Upper Gastrointestinal Bleeding (AUGIB)
8.2%7.1%Mortality after OGD
13%14%Re-bleeding rate
5 days6 daysMedian stay
254/1980
(13%)
586/2969
(20%)
1st Endoscopy OOH
No OOH rota (2821)
OOH on call rota (3499)
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
National Comparative Audit of Blood Transfusion National Blood Service
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
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 HearnshawMr John Grant-CaseyMr Derek LoweProf Richard LoganProf Tim RockallDr Simon TravisProf Mike MurphyDr Kel Palmer
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