Introduction The 2015 NCEPOD “Time to get control” report recommends that hospitals admitting patients with severe UGIB have access to critical care and anaesthetic support for urgent endoscopy. We examined our emergency pathway including theatre urgency codes, time to therapy and clinical outcomes.
Methods We analysed all patients who had emergency endoscopy in theatre for suspected severe UGIB at Queen’s Medical Centre, Nottingham, UK, between 1st March 2014 and 28th February 2015. We examined patient demographics, ASA and UGIB risk scores, shock index (SI; heart rate/systolic BP), referral times to endoscopy and breach rates, anaesthetic and operator details, endoscopic findings and therapy (blood product use, interventional radiology and surgery), procedural documentation, re-bleed plans, discharge location, complications and inpatient mortality.
Results 95 patients (60 male mean [±SD] age 59.2 [±19.1]; 35 female, 55.2 [±28.4]) with suspected severe UGIB were treated in emergency theatres over the 12 month period. 93/95 (98%) had significant UGIB; 82% ASA grade ≥3 and Glasgow Blatchford Scores (GBS) were recorded in 18% of cases; median (range) score 12 (1–19). 64% were classified as theatre urgency 1 (U1; within 60 mins) and 25% U3 (within 180 mins). 64% of those in U1 had a high shock index (SI > 0.9). However, median time from referral to endoscopy was 215 (range 37–1370) minutes. 47% breached the theatre urgency code times; including 59% of those assigned to U1. A consultant gastroenterologist was present in theatre in 86/95 (91%) of cases and 96% of patients received a general anaesthetic with rapid-sequence induction. The UGIB was non-variceal in 55/95 (58%; endoscopic intervention in 63%), variceal in 32/95 (34%), no cause found 8/95 (8%). 70% received a blood transfusion within 24 hrs of admission, mean 2.7(±2.5) units packed cells. 9/95 (10%) had CT angiography and 6/95 (6%) underwent coil embolization. No patients underwent surgery. An endoscopy report was generated for all cases, but re-bleed plans were only documented in 51%. Following endoscopy, 63/95 (67%) required a high-dependency bed and inpatient mortality was 21%.
Conclusion Patients undergoing emergency endoscopy in theatre for acute UGIB had high risk scores and inpatient mortality, but 47% breached theatre urgency timings. These delays may impact on patient outcomes and are likely multifactorial. Potential reasons include time for resuscitation, transfer from admitting areas and co-ordination of emergency endoscopy teams and equipment. These logistics need to be understood more and improved to achieve improvements in patient care.
Disclosure of Interest None Declared
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