UK Comparative Audit of Acute Upper Gastrointestinal Bleeding (AUGIB) and the use of Blood - PowerPoint Presentation

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UK Comparative Audit of Acute Upper Gastrointestinal Bleeding (AUGIB) and the use of Blood (3rd May-2nd July 2022)

National Comparative Audit of Blood Transfusion

Dr Gaurav Nigam

Academic Clinical Fellow (ST4) Gastroenterology Thames Valley (Oxford)

BackgroundAUGIB is a common medical emergency, with

10% mortality and accounting for approximately 11% of units of red cell concentrates used in hospitals across EnglandThe 2007 UK wide audit involving data on 6750 patients from 212 hospitals highlighted several deficiencies in resource availability and management strategies

Since then, there have been various initiatives to improve management of AUGIB improvements in service delivery including provision of 24/7 access to emergency endoscopy and ready access to interventional radiology development of international guidelines on management of variceal & non-variceal upper GIBChanges in pre-endoscopic, endoscopic and post-endoscopic management of AUGIB Clinical risk scores for risk stratification and multi-society care bundle for AUGIB to improve quality of careButton LA et al.

Aliment Pharmacol Ther. 2011;33:64–76.; Tinegate H et al. Transfusion. 2013;53:483–9; Hearnshaw SA.

Gut 2011; 60:1327-35. ;Siau K, et al. Frontline Gastroenterology 2020;11:311–23; Stanley AJ, Laine L. BMJ 2019; 364:l536 

Timeline in management of AUGIB

Rockall Score (1996), Glasgow-Blatchford score (2000) from regional UK audits

2007 UK AUGIB audit

Highlighted several deficiencies in resource availability and management strategies

2012 NICE guidelines on AUGIB

CHROME statement on services for AUGIB

2015 NCEPOD Report to improve care for GI haemorrhage

2015-2021: Updated National and International guidelines on management of variceal and non-variceal upper GI bleeding

2020 BSG led multi-society care bundle for AUGIB

2022 – UK AUGIB audit

Assess changes and impact on management on AUGIB across the UK

An appropriate time to repeat a UK wide audit of AUGIBAssess improvements : resource availability, clinical assessment, management, transfusion practice and patient outcomesData will be used to clarify areas of ongoing clinical uncertainty Optimal risk assessment scores: low-risk and mortality predictions

Optimal timing of endoscopy, relationships between out of hours presentation and outcomesAim to improve training in AUGIB managementUnderstand the resources available for training and to assess the skills and confidence of current trainees in management of AUGIB

Role GI trainees can play in improving careGenerate evidence to improve training given the changes expected to shape of trainingNeed for the re-audit

All NHS Trusts in England, Northern Ireland, Wales and Scotland will be contacted about the audit planned for 3rd May-2nd July 2022

Prospectively identified consecutive patients with AUGIB during this period will be included for the auditGather information on quality of AUGIB management, service provisions as well as availability and access to training resources

Similar to 2007, participating sites will receive data specific to their hospital so that they can compare their practice with the UK wide results. Seek special support from trainees to get maximum responses to get required information during this national auditHelp improve quality of training and clinical careAcknowledge contribution for audit

Audit questionnaires

Key Personnel

Case IdentificationAll cases of AUGIB, between

3rd May until 2

nd July 2022Resulting in a presentation to hospital or developed whilst patients were already hospitalised for another reasonPatients do not need to have had a blood transfusion/endoscopy to be eligible Case identifiers should aim to enrol consecutive cases if they meet the following criteria: Patients aged ≥ 16, presenting to hospital or admitted to an adult medical/surgical wardSuspected or confirmed AUGIB (melaena, haematemesis, shock / syncope, coffee ground vomiting)Suggest highlight at medical grand round / postgraduate meetings / F1 / F2/ IMT teaching and display posters

Audit tool

Audit lead decides whether true case and eligible for inclusion

Online data entryData to be collected from patient’s case notes & hospital IT systemsShould take 30-45 minutes per caseOnline help notes will be available for every question

Demographics

Clinical history

Laboratory tests

Medications

Interventions

Clinical outcomes

Age, gender, ethnicity.

Admission date, time, clinical area, and admitting team. Referral patterns (e.g. to Gastroenterology / Surgery/ critical care), past medical history, signs and symptoms at presentation, observations at time of presentation for the clinical episode.

Results of blood tests performed for the clinical episode. Details of specific medications administered with dose and duration. 

Details of interventions (endoscopy, transfusion, surgery, interventional radiology) with information on the time of intervention and outcomes. Details on clinical outcomes including final diagnosis, safe discharge, in-patient deaths and cause of death, need for a repeat procedure etc. 

Organisational audit

Use of protocols for AUGIB management, and their content, including use of risk assessment tools and guidance on blood transfusion Information on GI bleed rota and additional on call GIM commitments

Availability of emergency endoscopy, interventional radiology (including transfer of patients and repatriation policies), surgery and endoscopy nurse cover Data on all the above will be requested separately for in and out of hours including at weekendsTo be completed by endoscopy lead with assistance from audit lead, if required

Trainee resourcesExploring current involvement and training opportunities for GI trainees in management of AUGIBTo be completed by the clinical lead for gastroenterology or endoscopy with assistance from audit lead, if required

Also seek information from individual trainees on their competence levels for management of AUGIB.

After the auditThe audit will report its findings by December 2022

Each hospital will receive a written report that will allow comparison of the practice of individual hospitals against their regional peers, as well as against the national picture

Encouraged to present results locally - medical grand round / post-graduate meetingsNational (and international) presentations of results

Impact and AcknowledgementPrevious UK audits have led to

multiple high-impact factor publications important insights to implement significant changes to service delivery and improving care for our patients. 

Exciting opportunity Complete an audit as part of your training Gain acknowledgement in anticipated publications from this work Consideration for full authorship will be given based on contributionCovers the ARCP requirements for audits

Questions?Details and slides outlining whole study at

bsg.org.uk/GI-Bleed-AuditVirtual drop-in sessions organised with the NCA team go through the steps for use of audit data tool (schedule will be e-mailed)

Email: Gaurav.nigam@nhs.netData entry / technical / logistics questions to: NCA@nhsbt.nhs.uk

Thank you!!!Thank you very much for all your hard work. If there are any concerns, please do contact usGood communication between all of us will ensure the audit runs well

Good luck and stay in touch!

Dr Andrew DoudsConsultant Gastroenterologist Norfolk and Norwich University HospitalChair of Audit Steering Committee

Professor Adrian Stanley

Consultant Gastroenterologist & Honorary Professor, Glasgow Royal InfirmaryProfessor Simon TravisProfessor of Clinical Gastroenterology & Consultant Gastroenterologist, Translational Gastroenterology Unit, Oxford University Hospital

Professor Mike MurphyProfessor of Transfusion Medicine & Consultant Haematologist NHS Blood and Transplant

, Oxford University Hospital

Professor Richard Logan

Professor of Epidemiology, University of Nottingham

Professor Vipul JairathProfessor of Medicine, Epidemiology and Biostatistics, Western University, London, Canada 

Dr Sarah

Hearnshaw

Consultant Gastroenterologist

Newcastle upon Tyne Hospitals

Dr Gaurav Nigam

Academic Clinical Fellow- Gastroenterology/Transfusion Medicine,

Translational Gastroenterology Unit,

Oxford University Hospital

Dr Jo

Leithead

Consultant Hepatologist, Forth Valley Royal Hospital

BASL Representative on Audit Steering Committee Dr Lise EstcourtAssociate Professor of Haematology And Transfusion Medicine & Consultant Haematologist, NHS Blood and Transplant, Oxford University HospitalDr Kate OaklandDirector of Medical Services, HCA Healthcare UK

Dr Raman UberoiConsultant Interventional Radiologist, Department of Clinical Radiology, Oxford University Hospital

BSIR Representative on Audit Steering Committee Mr Bhaskar KumarConsultant Surgeon, Norfolk and Norwich University HospitalAUGIS Representative on Audit Steering Committee Dr Elizabeth RatcliffeClinical research fellow Wrightington Wigan and Leigh NHS trust , BSG trainees section chair 2020-2021

Mr John Grant-Casey

Programme Manager, National Comparative Audit of Blood Transfusion, NHS Blood and Transplant2022 National UK AUGIB audit Steering committeeDr Paula DhimanSenior Researcher in Medical Statistics,

Centre for Statistics in Medicine,

University of OxfordMr Paul DaviesSenior Clinical Audit Facilitator, National Comparative Audit of Blood Transfusion, NHS Blood and Transplant