Article Text
PDF
Abstract
Background There has been a drive to raise the standard of management of acute upper gastrointestinal bleeding (AUGIB) in the UK, including three previous audits, sponsored by the British Society of Gastroenterology (BSG).
Objective To review the results of the latest BSG/National Health Service (NHS) England national survey of endoscopy services in England between 2014 and 2015.
Method All NHS hospitals accepting acute admissions in England (168) were invited to respond to the survey.
Results Overall, 142 hospitals (84%) returned data. 85% of hospitals used a validated risk assessment score at the time of patient's admission. While 80% of hospitals provided a 24/7 endoscopy service for unstable patients, and another 10% were in network to provide an acute service, only 60% performed an endoscopy within 24 hours for stable acute admissions or inpatients with AUGIB. 11% of hospitals operated an out-of-hours ad hoc rota. 43% felt that pressure from routine work affected their ability to offer a next-day oesophagogastroduodenoscopy service, while 20% of hospitals struggled to recruit endoscopists. 28% of units reported that the previous national audit performed in 2013 had a positive influence on service development.
Conclusions This survey has revealed significant deficiencies in provision of services for patients with AUGIB in England, without a significant increase in number of hospitals providing an emergency AUGIB service since the last national audit in 2013.
- GASTROINTESTINAL BLEEDING
- ENDOSCOPY
- BLEEDING
- ENDOSCOPIC PROCEDURES
Statistics from Altmetric.com
Introduction
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies, with an incidence of approximately 90 000 cases per year in the UK.1 This is equivalent to one GI bleeding every 6 min, with an overall 10% mortality.2
There has been a drive to raise the standard of management of AUGIB in the UK, including three previous audits, sponsored by the British Society of Gastroenterology (BSG). The first audit of AUGIB in the UK was performed in 1993 across four healthcare regions,1 and reported an overall mortality rate of 14%. The second audit was performed nationally,2 and reported significant deficiencies in provision of service, for example, only 52% of hospitals had a formal consultant-led out-of-hours (OOH) endoscopy service. Despite this, the mortality rate had improved compared with 1993 (7% vs 11% in those admitted as an emergency with upper GI bleeding and 26% vs 33% in those who developed an upper GI bleeding while in hospital). The last round of audit, which was performed in 2013,3 focused mainly on the organisation aspects of the service within England.
These audits have been performed against the backdrop of guidelines on the management of acute upper and lower GI bleeding by Scottish Intercollegiate Guidelines Network (SIGN) in 20084 and the quality standards document on the management of upper GI bleeding by National Institute for Health and Care Excellence (NICE) in 2012.5 In 2010, the BSG and the Royal College of Physicians produced a toolkit for safer upper GI bleeding services6 outlining nine service standards including one which specifies that ‘for patients who require more urgent intervention either for endoscopy, interventional radiology or surgery, formal 24/7 arrangements must be available’.
This paper reviews the results of the latest BSG/National Health Service (NHS) England national survey of endoscopy services in England between 2014 and 2015.
Method
Survey questions were agreed by the authors. All NHS hospitals accepting acute admissions in England (168) were invited to participate in the study. In December 2014, lead clinicians of each endoscopy unit were asked to complete an online questionnaire asking about service arrangements for AUGIB in their hospitals. In February and March 2015, units that had failed to respond were recontacted. In total, 142 (84%) hospitals returned data.
Results
All the survey questions are presented here with the same wording as they appeared in the survey. A list of the questions is provided in online supplementary appendix 1.
Supplementary appendix
Table 1 summarises the organisational aspects of services, in relation to the questions asked regarding specific sections from the published guidelines and standards.i Response rate: 142 (out of 142 original responders)—questions were mandatory.
Summary of organisation of endoscopy services in England
Other questions asked in the audit:
Does your department use a validated risk assessment score (eg, Blatchford/Rockall) when admitting patients with AUGIB? Response rate: 142 (out of 142 original responders) (figure 1).
Use of validated assessment scores for patients with acute upper gastrointestinal bleeding (AUGIB) at time of admission (one hospital uses a locally modified version of Rockall score, and was counted as not using a validated risk assessment score).
If you can offer an OOH service but not a next-day service, what stops you offering a next-day oesophagogastroduodenoscopy service for those bleeders who are stable? Response rate: 65 (out of 142 original responders) (table 2).
Factors preventing endoscopy units from delivering next-day oesophagogastroduodenoscopy service for stable bleeders
If, since the March 2013 survey, you have introduced an OOH service for patients with AUGIB, how did you achieve this? Response rate: 19 (out of 142 original responders) (figure 2).
Methods and triggers used by units to introduce OOH service for AUGIB since March 2013 survey. %, percentage of responders; AUGIB, acute upper gastrointestinal bleeding; CQC, care quality commission; GIM, general internal medicine; OOH, out-of-hours.
Did the findings of the endoscopy survey undertaken in 2013 influence service development? If so how? ‘Yes’ 36 (28%) (24 of 36 respondents provided an explanation); response rate: 139 (out of 142 original responders) (figure 3).
Influence of the 2013 endoscopy survey on AUGIB service development in endoscopy units. %, percentage of responders providing an explanation; AUGIB, acute upper gastrointestinal bleeding; NICE, National Institute for Health and Care Excellence.
Do you have a surgical rota able to provide the surgery necessary in case of failure to control upper gastrointestinal haemorrhage by endoscopic or interventional radiology methods? Response rate: 142 (out of 142 original responders) (figure 4).
Availability of emergency surgical services for treatment of uncontrollable acute upper gastrointestinal bleeding in National Health Service hospitals in England.
Are there any issues that you want to let us know about, which have not been covered in this survey? Response rate: 40 (out of 142 original responders) (table 3).
Main reported challenges of setting up AUGIB services facing endoscopy units (free-text field; multiple reasons provided by responders)—a sample of the free-text responses has been provided in online supplementary appendix 2
Supplementary appendix
Discussion
Over the last 20 years, significant effort has been made to improve the clinical and organisational care of patients with AUGIB. The evidence for early endoscopy has been conflicting, with some studies suggesting that early endoscopic intervention does not change outcome.7 However, more recent studies have suggested that early endoscopy may reduce resource utilisation, improve patient outcome and reduce mortality.8 ,9
It is now widely accepted that the gold standard for AUGIB should include 24/7 access to specialists in endoscopy, interventional radiology and surgery.5 ,6 ,10–12
In this survey, 84% of Trusts in England responded. It is noteworthy that 85% of units that replied are using risk assessment scores, which can help stratify risk and can either predict mortality13 or the likelihood of needing endoscopic intervention.14 While 80% of hospitals reported providing a 24/7 endoscopy service for unstable patients and another 10% are in networks to provide an acute service, only 60% said they perform an endoscopy within 24 hours for stable acute admissions or inpatients with AUGIB. Just under 8% of hospital Trusts did not have any arrangements for OOH endoscopy. These figures have not changed significantly since the last audit in 2013 (77% OOH service and 56% endoscopy within 24 hours). The three most common reasons cited for lack of a next-day service are: pressure from elective work, lack of routine lists at weekends and acute medical/surgical commitments.
The 2013 audit3 highlighted three case studies as to how an AUGIB service can be provided and showed that patients can be safely transferred between acute sites.15 It appears that the results of the previous audit have had a positive influence on service development in almost 30% of hospitals, either through raising awareness of new models of service delivery, such as cross-site cover, protected morning endoscopy time, developing an OOH nursing rota or raising awareness among the senior managers.
It is also encouraging that since the last audit in 2013, 19 units have started an OOH service. This has been achieved primarily by medical endoscopists coming off the general medical on-call rota, increasing endoscopy staff or organising cross-site cover. The 2013 survey also had a positive effect on service development and responders reported that it had helped raise the awareness of the issue of OOH bleeding with hospital management. However, in three trusts an OOH rota has been achieved by creating an informal internal rota, creating extra pressure on the consultants. Indeed, participating in two on-call rotas (endoscopy and general medicine or surgery) is very common, with consultants in 70% of hospitals reporting such an arrangement.
Perhaps what is more disappointing about this survey is the difficulty in providing an endoscopy within 24 hours for stable patients with AUGIB. Some common themes have emerged in this survey regarding the challenges faced by departments in delivering an optimal service. These include pressures of elective endoscopy, lack of routine endoscopy lists at the weekend, on-call commitments of other rotas, difficulties in recruiting endoscopists, challenges of cross-site working and lack of engagement from senior managers.
Soon after the completion of this survey, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a report into the care received by patients who had suffered a severe GI haemorrhage, ‘Time to Get Control?’ The report's findings (based on 2013 data) on OOH endoscopy availability and next-day scope availability are broadly similar to the current survey.
The challenges described in this survey for the delivery of an endoscopy service come at the same time as many other pressures on GI endoscopy services including the need to deliver colorectal cancer screening, the need to cope with increasing referrals and a lower threshold for possible symptomatic GI cancers as well as uncertainty about the source of the expansion that is needed in the number of trained GI endoscopists. Each of these issues will need some specific solutions, but all of them require increased endoscopy capacity.
Conclusion
This survey and the NCEPOD report reveal some serious organisational deficiencies in service provision and described significant shortcomings in clinical care of patients with AUGIB in England. The NCEPOD report has made a number of recommendations, the first of which was that patients with acute GI bleeding should only be admitted to units with 24/7 access to on-site endoscopy, interventional radiology (on-site or networked), on-site 24/7 surgery and critical care. This is in keeping with the move towards 7-day working in the NHS.5 ,16 ,17
The evidence from this survey indicates that a number of units would struggle to meet these recommendations. While there is evidence of improvement in recent years, much work is needed to raise the national standard of endoscopy services to an acceptable level. The organisational challenges are clearly described and the frustration felt by clinicians delivering these services is all too real, as evidenced by responses we have received to this survey. We hope that this survey can be a further stimulus to units to help improve access to endoscopy for patients suffering from AUGIB.
Key messages
What is already known on this topic?
Therapeutic endoscopy after acute upper gastrointestinal bleeding (AUGIB) has been shown to reduce rebleeding and the need for surgery.
Early endoscopy after AUGIB may reduce resource utilisation, improves patient outcome and reduces mortality.
In England, access to out-of-hours (OOH) endoscopy was only available in 77% of hospitals admitting patients with AUGIB in 2013.
What this study adds?
In this survey, 80% of hospitals provided OOH endoscopy service (compared with 77% in the 2013 national survey).
Consultants in 70% of hospitals participated in two on-call rotas (endoscopy and general medicine or surgery).
Twenty-eight per cent of units reported that the previous national audit performed in 2013 had a positive influence on service development.
How might it impact on clinical practice in the foreseeable future?
We hope that this survey can be a further stimulus to units to help improve access to endoscopy for patients suffering from AUGIB.
Acknowledgments
The authors are immensely grateful to all the consultants, nurses and others responsible for responding to the survey at the participating hospitals, and to the Joint Advisory Group for sending the survey to all the endoscopy units.
References
Footnotes
Contributors BN-S contributed to the design of the survey, analysed the data and wrote the manuscript. ERED and MG contributed to the design of the survey and to the writing of the manuscript. SMG designed the survey, ran the data collection, advised on data analysis and contributed to the writing of the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i Criteria derived from published BSG, SIGN and NICE guidelines and UGIB toolkit.