Deficiencies in services for acute upper gastrointestinal bleeding
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4774 (Published 11 September 2015) Cite this as: BMJ 2015;351:h4774
- Alan J Lobo, honorary professor of gastroenterology12,
- Simon M Greenfield, chair, clinical services and standards committee 34,
- Ian Forgacs, president35
- 1Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK
- 2Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- 3British Society of Gastroenterology, London, UK
- 4Department of Gastroenterology, Lister Hospital, Stevenage, UK
- 5Department of Gastroenterology, King’s College Hospital, London, UK
- Correspondence to: alan.lobo{at}sth.nhs.uk
Acute upper gastrointestinal bleeding is a common and serious medical emergency. There are an estimated 50 000-70 000 hospital admissions in the United Kingdom a year1 2and overall mortality is about 10%.3 A new report by the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) identifies continuing difficulties in the provision of services for patients with substantial bleeding,4 reinforcing earlier findings from national audits5 and NHS England.6 The report focuses on patients with severe bleeding who require transfusion of at least four units of blood.
The optimum management of acute upper gastrointestinal bleeding requires a combination of circulatory resuscitation, risk assessment to help predict the need for intervention as well as outcome, administration of blood products, drug treatment, upper gastrointestinal endoscopy with haemostatic endotherapy, interventional radiology, and surgery when necessary.1 The NCEPOD report highlights deficiencies in each of these areas.
According to national audits, mortality from acute upper gastrointestinal bleeding fell in the UK between 1993-47 and 20073; the reduction was attributed, at least in part, to the use—and efficacy—of endoscopic treatments such as injection of adrenaline, thermocoagulation, or application of clips.3 Quality standards issued by the National Institute for Health and Care Excellence (NICE) require that all patients with acute upper gastrointestinal bleeding have endoscopy within 24 hours and that those with unstable bleeding have an endoscopy within two hours of optimal resuscitation.8 Early endoscopy is associated with improved outcomes in terms of rebleeding, need for surgery, length of stay, and cost9 but its effect on mortality has been harder to demonstrate. It is, however, associated with lower mortality in high risk patients with non-variceal upper gastrointestinal bleeding.10 In one UK audit, patients admitted to a hospital with a formal out of hours service for upper gastrointestinal bleeding were more likely to have their first endoscopy and receive endoscopic treatment out of hours than those admitted to a hospital without a formal out of hours service.5
In 2013, the British Society of Gastroenterology and NHS England jointly surveyed endoscopy units in all acute hospitals in England to determine their ability to meet the NICE standards on timing of endoscopy. Although 77% of hospitals were able to deliver emergency endoscopy round the clock, only 56% could provide endoscopy to all patients with acute bleeding within 24 hours.6 The new report finds a comparable pattern, with three quarters of eligible hospitals having out of hours provision. However, only 65% of patients requiring at least four units of blood reviewed by NCEPOD had an endoscopy within 24 hours of admission. Of those with evidence of additional haemodynamic compromise, 20% had not had endoscopy at 24 hours.4
Organisational challenge
Insufficient numbers of endoscopists, their competing commitments to acute general medical admissions, poor availability of endoscopy nurses, and lack of executive support were all cited as barriers to providing a 24/7 endoscopy service.6 Exchange of general medical commitments for a seven day gastroenterology service and development of out of hours endoscopy networks among endoscopists in neighbouring hospitals are potential solutions.11 The sustainability of a dedicated out of hours emergency service staffed by consultants and the impact of such a service on consultants’ elective work need to be considered as well as ensuring that training programmes deliver consultants with appropriate experience.12
In the NCEPOD report, 92% of patients under the primary care of a gastroenterologist received “timely” endoscopy. The report’s authors call for involvement of a gastroenterologist within one hour of a patient presenting with a major bleed. The model of a dedicated gastrointestinal bleed unit allows coordination of care and has been associated with both high rates of endoscopy within 24 hours (93%) and reduced mortality.13
Patients should be considered for radiological interventions—computed tomographic angiography and transarterial embolisation—when therapeutic endoscopy fails to control their bleeding.1 NCEPOD recommends that patients with an acute gastrointestinal bleed should be admitted or transferred only to hospitals with 24/7 access to on-site endoscopy and surgery, while interventional radiology must be available either on-site or within a formal network. Only 7.8% of patients in the NCEPOD review had a radiological intervention. Appropriate radiology services were available round the clock in just 30% of hospitals. Case reviewers thought that more patients could have benefited from these services, but the report suggests a shortage of at least 200 appropriately trained radiology consultants in the UK.4
The requirements for safe management of upper gastrointestinal bleeding have been clearly and repeatedly documented.1 8 The new report gives a further stimulus to improve these services—and offers an opportunity that must be grasped. Senior clinicians and managers at every hospital in the UK should now examine the report’s recommendations together with NICE quality standards and assess what they need to do to ensure a service that will deliver timely effective care to all those with suspected upper gastrointestinal bleeding. Each component of the care pathway should be scrutinised, but in particular the out of hours provision of emergency gastrointestinal endoscopy.
Notes
Cite this as: BMJ 2015;351:h4774
Footnotes
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: AJL was an advisory board member for Takeda UK and Vifor Pharma, received travel and accommodation expenses to attend the European Crohn’s and Colitis Organisation in February 2015, and was an unpaid member of NICE guideline development groups for Crohn’s disease and ulcerative colitis and its quality standards advisory committee for inflammatory bowel disease.
Provenance and peer review: Commissioned; not externally peer reviewed.