gi bleeding_grand round_liverpool_17 nov 2016

03/05/2023 1

National Comparative Audit of Lower Gastrointestinal Bleeding and the

Use of Blood:

FINDINGS AND INTERPRETATIONS

Raimundas Lunevicius, Jūratė Noreikaitė, Mohammed Elniel

Grand RoundsAintree University Hospital NHS Foundation Trust

LiverpoolNov 15th, 2016

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Agenda for 20-25 minutes• The necessity of this audit

• Methods• Results: key finding – at the national and site-specific levels

( Aintree)

• Interpretations– ‘MD Bulletin’ to mention

Introduction

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Problem• 19,000 admissions with LGIB / UK / year • Becoming much more common• Practice is suboptimal; assumption based on concerns:

– re inappropriate use of blood components in GIB– re too small proportion of pts undergoes investigations during index adm.

• An objective evaluation of performance against a set of standards to produce a piece of evidence was required to understand the processes of care and outcomes, and to identify areas for improvement

Introduction

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Initiatives and funding• Stakeholders

– NHS Blood and Transplant– Association of Coloproctology of Great Britain and Ireland– British Society of Gastroenterology – British Society of Interventional Radiology

• Funding– NHS Blood and Transplant & the Bowel Disease Research Foundation

• Report– Online – Aintree specific results are NOT available online

Introduction

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Methods

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Hospitals, criteria, time-frame• 174 hospitals of 4 constituent countries of the UK invited• Duration: 1 Sep 2015 - 31 Oct 2015• The cases / inclusion criteria:

– Adults ≥16– Admission with PR bleeding without haematemesis– Admission and ≥24 hours stay in the hospital– Inpatient with other underlying illness and PR bleeding

• 28 days given for observation of a patient and data collection• The electronic questionnaire included 180 questions• Set of 17 standards declared

Methods

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No national guideline and standards for LGIBHow the standards for audit been selected?

• Guidelines adapted for this audit • From six resources as 17 specific point standards• Resources:

1. SIGN 2008 (Scotland) 2. NCEPOD report on GI bleeding3. BSG and NICE guidelines on UGIB4. BCSH and NICE guidelines on the use of blood components5. Recommendations made by ASGBI, NELA, BSIR6. Consensus opinions

Methods

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17 standards for

• Clin. Examination & Bedside tests: 1,2• Laboratory Tests for LGIB: 3• Medicines Management: 4, 5, 6, 7• Blood Component Transfusion: 8 – 12• The Investigation of LGIB: 13, 14• Surgery: 15 – 17

Methods

Laboratory tests

Clinical examination and blood tests

Investigation of LGIB

Surgery

Medicines management

Blood component transfusion

0% 5% 10% 15% 20% 25% 30% 35%

6%

12%

12%

18%

23%

29%

Percentage weight of a cluster of standards

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Results

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Identified & eligible casesResults

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Participation: UK• 143 / 174 hosp. provided patient or organization of care spec.

data

• 139/143: provided data on 2,528 patients

• Average identified potential & eligible cases per site was– 20 potential & 18 eligible cases in two months (1 bleeding in 3-4 days)

• How did Aintree work ?

Results: patient specific

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Aintree patients• Identified potential

cases: 78– 1 or 2 patients a

day

• Eligible cases: 52EGSU Gastro ITU Ward 20 AMU Other

12 wards

0

5

10

15

20

25

30

35

30

14

5 5 4

20

Patie

nts


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UK: key findings (n= 2,528)

• Median age 74 • M / F: 1:1 • Comorbidities: 79% hypertension, DM, chronic respiratory disease

• On oral anti-platelet or anticoagulant: 43%• RBC: 27%• CT-scan of the abdomen & pelvis: 21%

• Invasive mesenteric angiography: 1.5% (37)• Angio-embolisation: 0.8% (19)

• Flexible sigmoidoscopy or colonoscopy whilst admission:26%


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UK: key findings (n= 2,528)

• Proportion of no inpatient investigations to identify a source of bleeding: 49%

• Laparotomy for LGI bleeding: 0.2% (6)• Trans-anal surgery for bleeding: 1.1% (26)• Re-admission rate within 28 days: 13% (260)• Mortality at 28 days: 3.4% (85)


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Organisation specific findings N=143

• 73% (104 / 143)– provide onsite 24/7 access to LGI endoscopy

• 55% (79)– reported 24/7 onsite or network access to IR

• 21% (30) – reported that elderly patients with LGIB were

reviewed by DME physicians (!)

Results: organisation of care specific

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Performance against 17 standards

• UK • Aintree (site)

Results

1 2 3 4 5 6 7 8A 8B 9 10 11 12 13 14 15 16 170%

10%20%30%40%50%60%70%80%90%

100%

Performance (practice) = standards (theory)

Number of a standard

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UK vs. AintreeNational cohort: UK (2528) Site: Aintree (52)

16 3 10 17 11 15 8B 7 20

10

20

30

40

50

60

70

80

90

100

StandardPerformance

Number of a concrete standard

Perc

enta

ge

10 3 5 13 8B 2 90

10

20

30

40

50

60

70

80

90

100

StandardPerformance


Perc

enta

ge

Results

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Clinical Examination & Bedside tests: standards 1 and 2

Standard – % (n) of patients meeting / met the standard

UK: 2528

Site: 52

1. All pts. admitted with LGIB should undergo DRE (SIGN 2008)

86.7%2191

71.1%38

2. All pts. with rectal bleeding should undergo proctoscopy or rigid sigmoidoscopy (SIGN 2008)

3.4%73/2178

0%0/48

Results

1 20

102030405060708090

100

StandardUKAintree

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Laboratory Tests for LGIB: standard 3

Standard – % (n) of patients meeting / met the standard

UK: 2528

Site: 52

3. LGIB: should have a FBC, coagulation screen, biochemistry (consensus opinion)

84.5%2135

86.5%45

Results

Standard UK Aintree0

102030405060708090

100

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Medicines Management: standards 4-7Standard – % (n) of patients meeting /

met the standardUK: 2528

Site: 52

4. Continue low dose aspirin for secondary prevention of vascular events in patients with LGI bleeding in whom haemostasis have been achieved (EH / IR) or are considered to have stopped bleeding spontaneously (developed from NICE 2012)

78.7%424/539

87.5%7/8

5. Stop other NSAIDs (incl. cyclooxygenase-2 inhibitors) during the acute phase in pts. presenting with LGIB (developed from NICE 2012)

61%89/146

33.3%1/3

6. Emergency anticoagulation reversal in major haemorrhage (53 pts – 2%) should be with 25-50 U/kg PCC and 5 mg Vit. K IV (BSCH 2013)

40%2/5

No data breakdown by site

7. Reversal for non-clinically significant bleeding should be with 1-3 mg IV vitamin K (BCSH 2013): 10.8% (270) were taken warfarin

18.2% (20/262)

0% (0/4)

Results

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Medicines Management: standards 4-7

4 5 6 70

10

20

30

40

50

60

70

80

90

100

StandardUKAintree

Number of standard

Perc

enta

ge

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Blood Component Transfusion: 8- 12Standard – % (n) of patients

meeting / met standardUK: 2528

Site: 52

8A. Use restrictive RBC transfusion thresholds (70 g/L) for pts. who need RBC transfusions and who do not have major haemorrhage (MH) or acute coronary syndrom (ACS) (NICE 2015)

8B. Use a HB concentration target of 70-90 g/L after transfusion for pts. who need RBCTs & who don’t have MH or ACS (NICE 2015)

19.5%(117/599)

19.2%(115/599)

23.1%(3/13)

23.1%(3/13)

9. Offer platelet transfusion to pts. with LGIB who have significant bleeding & have a platelet count of less than 30 (dev. from NICE 2015)

0%0/44

0%0/2

10. Don’t routinely give more than a single adult dose of platelets in a transfusion

75.0%(33/44)

100%(2/2)

11. In LGIB, offer FFP to patients who have either an INR or APTT ratio greater than 1.5 times normal (developed from NICE 2012)

26.8% (15/56)

33.3% (1/3)

12. Use a dose of at least 15 ml/kg when giving FFT trans (NICE 2015)

7.1% (4/56)

0%

Results

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Blood Component Transfusion: 8- 12

8A 8B 9 10 11 120

10

20

30

40

50

60

70

80

90

100

StandardUKAintree

Number of standard

Perc

enta

ge

Results

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The Investigation of LGIB: 13, 14Standard – % (n) of patients meeting / met standard

UK: 2528

Site: 52

13. The cause and site of clinically significant LGIB should be determined following the early use (within 24 hours) of colonoscopy or flexible sigmoidoscopy or the use of CT-angiography or digital subtraction angiography (developed from SIGN 2008)

25%(9/36)

31.3%(5/16)

14. Patients with LGIB with clinically significant bleeding should have an OGD unless the cause has been established using another modality of investigation within 24 hours (dev. from NICE 2012)

19%(4/21)

14.3%(1/7)

Results

Standard

UK

Aintree

0 10 20 30 40 50 60 70 80 90 100

1413

Percentage

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Surgery: 15-17 Standard – % (n) of patients meeting / met standard

UK: 2528

Site: 52

15. When surgery is contemplated, a formal assessment of the risk death & complications should be undertaken by a clinician & documented (adapted from ASGBI 2012 and NELA 2015)

22.9%(11/48)


16. Surgical procedures with a predicted mortality > 10% should be conducted under the direct supervision of a consultant surgeon (CCT holder) and consultant anaesthetist unless the consultants are satisfied that the delegated staff have adequate competency, experience, manpower and are adequately free of competing responsibilities (ASGBI 2012)

100% (3/3)


17. Localised segmental intestinal resection or subtotal colectomy is recommended for the management of colonic haemorrhage uncontrolled by other techniques (SIGN 2008)

60% (3/5)


Results

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Surgeries in 139 hospitals of the UK: 5 / 2528

Surgery Indication Patients DeathsRight hemi-colectomy Angiodysplasia

Diverticular bleed2 0

Subtotal colectomy Non-Hodgkin’s lymphomaDiverticular bleed

2 2

Anterior rectum resection

Rectum cancer 1 0

Mortality rate – 40% (2 deaths, 5 patients)

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Aintree-specific findings• Only 60% had their NSAIDs withheld• 1 out of 10 of patients with PR bleeding – on warfarin.

– the vast majority of them didn’t receive appropriate PCC or vitamin K

• Although presentation with shock was rare , 25% received RBCs– many of these transfusions may be deemed inappropriate.

• A 1/3 of patients that had significant bleeding didn’t have the source of their bleeding investigated– of those that underwent investigation, many waited more than 24 h

• No patients required emergency laparotomy

Results

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UK vs. AintreeNational cohort: UK (2528) Site: Aintree (52)

16 3 10 17 11 15 8B 7 20

10

20

30

40

50

60

70

80

90

100

StandardPerformance


Perc

enta

ge

10 3 5 13 8B 2 90

10

20

30

40

50

60

70

80

90

100

StandardPerformance


Perc

enta

ge

Results

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#1: The term: acute GI bleeding

• NOT – acute UGI bleeding– acute LGI bleeding

Water drop-8, NGS. ©mohammad reza shojaee

Interpretation

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#2:ConcentrationIn specialized unit for GIB management within GASTROENTEROLOGY

1. an elderly patient 1. major comorbidities, 2. often taking a ‘blood thinner’

2. requiring limited transfusions 1. 5% require large volume

transfusion

3. requiring radiology & endoscopy4. not requiring urgent surgery5. not having clinical diagnosis


Interpretation

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#3: Beauty of centralization

• Experience • Regular and easy audits• Reports to MD / CEO• Easy leading: regionally & nationally• Development of guidelines and pathways

and SOP afterwards• Teaching / research• Collaboration with DME• Less biased communication• Urgent or semi-urgent endoscopies• Reduction of duplication of functions &

variations in care provision• Better service at a lower cost


Interpretation

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Getting it right for every patient every time

MD bulletin, October 2016Dr. Steve Evans, Medical Director

• The 1st paragraph is about the funding of health and social care …

• The 2nd paragraph: ‘For us in Liverpool this merely intensifies the

pressures we are all experiencing on a daily basis and increases the

imperative for us to find better ways of working collaboratively across

our health system – our Sustainability and Transformation Plan aims to

reduce unnecessary duplication and variation in clinical services,

thereby providing a better service for our patients at a lower cost.’

• AN EXCELLENT CHANCE to lead along the proper pathway

Thank you

gi bleeding_grand round_liverpool_17 nov 2016

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