PTU-102 Are we compliant with NCEPOD guidance for gastrointestinal bleeding (GIB)?

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Abstract

Introduction

GI bleeding is a common emergency. NCEPOD 2015 guidance recommends Consultant input within 1 hour, to both major upper and lower GIB; performance of endoscopy within 24 hours for all patients, and within 2 hours of stability in haemodynamically unstable patients. This guidance was incorporated into our local Trust GI bleed pathway. We have a 24/7 GIB on call rota and inpatient endoscopy lists 6 days/week. We have previously used our electronic endoscopy requesting system to identify the source of any delays in performing endoscopy. Following this we modified vetting and booking practices. We aimed to audit compliance with NCEPOD guidance and against our previous audits.

Methods

Data were prospectively collated over 4 weeks from 6/2/17 to 5/3/17. Major GI bleeds were identified with either Glasgow Blatchford Score (GBS) score >8 or pre-endoscopy Rockall>5 or Shock index >1. Information was extracted from the hospital electronic health record and the Unisoft endoscopy reporting tool.

Results

42 patients presented with upper GIB (UGIB) and 9 with lower GIB (LGIB). 95% of patients with UGIB had a pre-endoscopy Rockall score documented, compared to 83.3% post endoscopy. Shock index was documented in 82.3% of all GIB patients.

Results

66.7% of patients with LGIB had a PR exam and only 33.3% also underwent proctoscopy. 66.7% of patients had a flexible sigmoidoscopy and 33.3% had a colonoscopy.

Results

15/51 of patients presented with major GIB, all of which were upper GIBs. 10/15 of these patients were discussed with the on-call Gastroenterologist within 1 hour (66.7% compliance). No patients presented with a major lower or upper GIB, with haemodynamic instability, during this time frame.

Results

80.4% underwent endoscopy within 24 hours. Table 1 demonstrates the breakdown of the mean cumulative length of time between each stage, from admission to undergoing endoscopy.

Conclusion

Our audit demonstrates improved compliance with NCEPOD and NICE guidance. Following changes to the endoscopy requesting process, the% of patients undergoing endoscopy within 24 hours has improved (26% vs 80.4% in this re-audit). However, the incorporation of LGIB into the pathway revealed poor rates of compliance with proctoscopy and PR examination. Better communication is necessary between the surgical and medical teams for patients presenting with LGIB. Rapid Consultant Gastroenterologist input to patients with a major GIB happens frequently but needs further improvement. The introduction of an on call Gastroenterology baton telephone, and junior doctor education have been used to support the on call medical registrar with this.

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