Introduction The management of acute upper GI bleeds (AUGIB) comes under greatest stress at weekends; this is a topical concern given the national drive towards a 7 day working week. We previously described the development of a centralised cross-county out of hours endoscopy service.1 We aim to critically appraise this service against NICE guidelines (CG141) and quality standards (QS38) for the management of AUGIB.
Methods Our computer-based endoscopy database was retrospectively analysed to identify patients undergoing gastroscopy (OGD) for AUGIB during the weekend in 2012. Full demographic information and OGD reports were identified in all 95 cases; complete patient records were located for 66 (69%) patients.
Results The average patient age was 71. 66% were new episodes of AUGIB: the rest had AUGIB during admission with different pathology. 11% (10) of patients did not survive their admission. 81% (76/95) had significant diagnoses on OGD. Of note, 38% (36) of patients had peptic ulcer disease, 8% (7) had cancer and 5% (4) had varices.
While 86% (57/66) of patients received a pre-endoscopy Rockall score, 11% had full Rockall scores, and only 3% had a Blatchford score documented. 55% (37) of patients underwent transfusion; half were overtransfused to a Hb >10 g/dL. Correction of coagulopathy was adequate in 4 of 6 patients. Platelet and recombinant factor VII use was in keeping with NICE guidance. 36% of patients inappropriately received intravenous PPI prior to OGD. Only 1 of 5 patients with suspected variceal bleeding received antibiotics and terlipressin at presentation.
6% (4/66) of patients remained haemodynamically unstable despite resuscitation – all had OGDs within four hours of admission. 88 and 95% of patients underwent OGDs within 24 and 48 h of admission respectively. The main reasons for delays were lags in submitting OGD request forms and inadequate fasting, rather than a lack of endoscopy capacity. All patients received appropriate endoscopic therapy modalities, and timely repeat OGDs or surgical intervention when warranted. All patients on aspirin for secondary prevention of vascular events were recommenced on aspirin when haemostasis was safely achieved.
Conclusion The trust provides a comprehensive out of hours endoscopy service, particularly for emergency cases with persisting haemodynamic instability. There remains scope for further improvement in pre- and post-endoscopy care. This exercise highlights the use of NICE-generated standards in guiding service development, and can be replicated in most district general hospitals.
Reference 1Shokouhi BN et al. The setting up and running of a cross-county out-of-hours gastrointestinal bleed service: a possible blueprint for the future. Frontline Gastroenterol 2013;4:3 227–231
Disclosure of Interest None Declared.
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