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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 2008Yorkshire & the Humber 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
• Yorkshire & the Humber RTC = 740 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
Hospital Code n = 16 Organisational? No. of cases = 740 % regional total
A Yes 14 2
B Yes 19 3
C Yes 45 6
D Yes 69 9
E Yes 28 4
F No 30 4
G Yes 86 12
H Yes 36 5
J Yes 56 8
K Yes 58 8
L Yes 63 9
M Yes 61 8
N Yes 36 5
P No - -
Q Yes 91 12
S No 48 6
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
10
20
30
40
50
60
Hospitals
%
9
27
14
1
95
722 5
1
8
1
1
2
874
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
UK A B C D E F G H J K L M N P Q S
Hospitals
%
3973
3327
37
2235
2815
43
17
27
24
9
828
41
0
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
UK A B C D E F G H J K L M N P Q S
Hospitals
%
1261
1
2
1
2
17
22
19
30
28
25
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
Hospitals
%
3499
342
8
10
18
34
13
10
32
1624
21
3031
13
59
23
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 = 24%
0
5
10
15
20
25
30
35
40
Hospitals
%
2241
179
4
4
14
12
7
5
11
12
13
17 19
12
8
32
9
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
Hospitals
%
2515/5004 276/517
8/14
2/14
25/39
21/48
14/23
2/10
21/45
17/28
20/47
27/40 29/41
21/41
16/2938/70 15/28
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
10
20
30
40
50
60
70
80
90
100
UK A B C D E F G H J K L M N P Q S
Hospitals
%
840/5004
1/14
0/14
9/3910/48
7/23
1/10 4/45
4/28
45/47
18/40
13/41
11/41
4/298/70 3/28
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
5
10
15
20
25
30
35
Hospitals
%
544/5004
59/517
1/14
0/14
5/39
8/48
2/23
3/452/28
4/47
5/40
3/41
1/29
12/70
3/10
6/41 4/28
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
5
10
15
20
25
30
35
40
45
50
Hospitals
%
1826/5004
170/517
2/14
13/39
12/48
10/23
18/45
13/28
19/47
17/40
14/41
27/70
7/41
3/28
1/14
4/10
10/29
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
Hospitals
%
335/517
34/53
0/1
4/5
3/7
1/2
2/3
5/10
4/6
3/4
5/5
1/21/21/2
3/3 1/1
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
Hospitals
%
598/789
51/67
2/3
4/5
5/7
0/1
3/8
3/4
4/5
16/19
1/1 1/13/3 4/45/5
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)
88
90
92
94
96
98
100
Hospitals
%
292/318
8/84/42/21/13/322/22 1/15/51/1
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 E F G H J K L M N P Q S
Hospitals
%
460/656
5/6
2/3
1/5
16/18
6/63/32/21/1 1/16/63/34/4
National Comparative Audit of Blood Transfusion National Blood Service
Process of care: Diagnoses
Acute Upper Gastrointestinal Bleeding (AUGIB)
Endoscopic finding %
Oesophagitis 24
Gastritis/ erosions 22
Ulcer 36
Erosive duodenitis 13
Malignancy 4
Mallory- Weiss 4
Varices 11
Portal Gastropathy 5
Vascular malformation 3
None 17
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
10
20
30
40
50
60
Hospitals
%
1377
127
7
2
10
9
4
1
13
5 9
12
10 10
4
28
3
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
Hospitals
%
3906
419 7
1128
46
14
14
59
19
28
37
3737
19
36
27
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%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A B C D E F G H J K L M N P Q S
Discharged within 28 days Alive in Hospital at 28 days Died
9 31 56 25 47 51 41 38 27 62 17 20 51 32 17
9
31 8 9
5
15 13
8
19 6
7
9 1
8 4 2 4
7 2 2 5
4 2 11 3 1
3
2
8
National Comparative Audit of Blood Transfusion National Blood Service
Risk standardised mortality ratio Acute Upper Gastrointestinal Bleeding (AUGIB)
Process of care: Outcomes
Hospital RSMR 95% CI
A 2.97 -0.39 to 6.34
B 0.61 -0.58 to 1.80
C 0.91 -0.12 to 1.95
D 1.63 0.67 to 2.59
E 0.87 -0.33 to 2.06
F 1.01 0.02 to 2.00
G 0.49 0.06 to 0.93
H 0.00
J 0.47 -0.18 to 1.13
K 0.32 -0.12 to 0.77
L 1.06 0.28 to 1.85
M 0.66 0.01 to 1.30
N 0.84 -0.32 to 2.00
Q 0.39 0.01 to 0.76
S 1.67 0.51 to 2.82
National Comparative Audit of Blood Transfusion National Blood Service
Service provision and outcomes
Acute Upper Gastrointestinal Bleeding (AUGIB)
OOH on call rota (3499)
No OOH rota (2821)
1st Endoscopy OOH 586/2969
(20%)
254/1980
(13%)
Re-bleeding rate 14% 13%
Median stay 6 days 5 days
Mortality after OGD 7.1% 8.2%
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 2008Yorkshire & the Humber RTC
British Society of Gastroenterology