Introduction The incidence of upper gastrointestinal bleeds is 50–150 cases per 100 000.1 The introduction of the CROMES: “Scope for improvement” toolkit2 has focused on the need for provision of a comprehensive GI bleed service. The RR-adjusted mortality in hospitals without an out of hours rota is 1.21 compared to those with a rota.1 Despite this only 52% of hospitals have a formal out of hours (OOH) endoscopy rota.1 The University Hospitals of Leicester (UHL) established a rota in 2006 which now provides 24/7 cover. We examined procedures performed since the rota was commenced.
Methods The audit period covered August to January for each of the five consecutive years. We analysed procedures carried out on weekdays (17:00–9:00) and weekends and Bank holidays (24 h). Data were gathered from OOH books where all endoscopies are recorded and from formal endoscopy reports (Unisoft). In each case we considered the indication for endoscopy; appropriateness for an “urgent” procedure; findings at index endoscopy and the need for therapeutic intervention.
Results The bulk of OOH work was performed on weekend mornings with weekdays accounting for much less; 6% in 2010–2011. Since commencement an increasing proportion of endoscopies were performed for “inappropriate” indications, as judged by UHL criteria (see Abstract PWE-193 table 1). There was an increase from 17% to 27% in the number of endoscopies where no pathology was found. Interestingly the proportion of patients with varices or variceal bleeds remained static at 9% throughout. Findings of peptic ulcer disease and gastritis/duodenitis have fallen by 16% over the period. The need for therapeutic intervention has almost halved. However, of those requiring intervention use of variceal banding and adrenaline injection significantly increased. Short-term outcomes were very good with over 90% of patients each year having their bleeding controlled and being returned to their ward. Longer-term outcomes were difficult to ascertain due to difficulties obtaining data.
Conclusion The data shows trends towards an increasing number of procedures with fewer positive findings and less need for therapeutic intervention. While this is likely to be multi-factorial, one likely contributing factor is the ever-present shortage of acute medical beds leading to more routine work in order to expedite discharges. This does not necessarily constitute a misuse of the service, as early specialist endoscopic input is likely to improve patients' management. However, these factors need consideration before offering such a service.
Competing interests None declared.
References 1. Hearnshaw S, et al. “Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK Audit”. 2010.
2. http://www.rcplondon.ac.uk/press-releases/new-guidance-stop-people-dying-acute-gastric-bleeding#main-content (accessed 10 Dec 2011).