Sudden, acute bleeding from the stomach is a common medical emergency, affecting around 30,000 people every year in the UK. One in 10 patients affected die as a result of the bleed, rising to one in four when acute bleeding happens to patients who are already in hospital for some other reason. A range of treatments including endoscopy, X-ray procedures and surgery can stop bleeding and save lives, and the earlier these treatments are used, the better the outcome. Unfortunately in the UK whilst 60% of patients are admitted outside of normal working hours:
- Almost half of hospitals lack out of hours endoscopy, interventional X-ray treatments are even less available and about a quarter of patients are admitted to units with no relevant surgical team.
- There is a lack of clarity concerning safe transfer of patients to referral centres where effective treatments are available.
A significant number of patients are therefore denied early access to potentially life saving treatments.
Preventing unnecessary deaths
New guidance launched today (Tuesday 15 March) aims to prevent unnecessary deaths with a toolkit that will improve the diagnosis and management of patients with acute gastric bleeding, particularly for those presenting at night and at the weekend. The toolkit was produced by the Academy of Medical Royal Colleges, the Association of Upper GI Surgeons, the British Society of Gastroenterology, Royal College of Nursing, Royal College of Physicians, and Royal College of Radiologists, with funding support from the National Patient Safety Agency.
Explore the background to the toolkit on the RCP site
The toolkit defines nine service standards that are required to manage this patient group and will form the basis of both commissioning and redesigning care at local level. It will overcome the gross inequalities that currently exist in this area.
Nine service standards
1. Appointment of a nominated clinical and administrative lead who will be responsible for implementation of an effective ‘bleeding service’.
2. Contracted providers will ensure that minimal service standards are resourced.
3. All patients will be assessed using standard validated risk scores that will inform their subsequent management.
4. Patients will be optimally resuscitated prior to endoscopic, radiological or surgical interventions.
5. All admitted patients should be endoscoped within 24 hrs of admission.
6. Critically ill cases may require very urgent therapeutic endoscopy, interventional radiology or specialist surgery and these must be either available locally 24/7 or arrangements must be in place for transfer to an adjacent hospital where these life saving treatments are available.
7. The team of doctors, nurses and technicians managing these patients should achieve defined competency levels and multi-disciplinary meetings should regularly take place.
8. Each stage of the patient journey must be undertaken in a safe environment including appropriate equipment and support from staff experienced in the care of this patient group.
9. All hospitals should collect a minimum data set in order to measure service provision against auditable outcomes.
Dr Kel Palmer, CROMES Clinical Director, said:
Approximately 70,000 patients are admitted to hospital each year because of acute upper gastrointestinal bleeding and 1 in 10 of these patients will die as a direct result of their bleeding. The audit we carried out clearly highlighted that there is a great inequity in service provision across the UK, which is exactly why we created the CROMES project – we need to define a range of service arrangements to manage patients presenting with upper gastrointestinal bleeding. We therefore hope that this toolkit can be used by hospitals to re-design services to provide 24/7 diagnosis and management for patients with UGIB.
We recognise that remote and rural hospitals with relatively limited numbers of practitioners cannot provide 24/7 management but the document does define minimal standards which all patients should expect and defines criteria for safe transfer to hospitals where emergency therapy can be applied.
The CROMES document is not another guideline for best practice, nor is it necessarily another call for more resources within a limited health service. Rather it is a document that should be useful to hospitals and commissioners in their aspirations to re-design optimum services for patients presenting with this common and life threatening problem.
Sir Neil Douglas, Chairman of the Academy of Medical Royal Colleges, said:
This guidance will undoubtedly lead to improved care for patients and will help save lives. It is an excellent example of the benefit of joint working across Colleges and professional bodies
Dr Suzette Woodward, Director of Patient Safety, NPSA, said:
Every patient with upper gastrointestinal bleeding should receive the right investigations, care and treatment when they need it, but reports made to the National Patient Safety Agency’s National Reporting and Learning System showed this did not always happen.* The Scope for Improvement toolkit provides an inspiring, comprehensive, and very practical resource to support the provision of safe services for patients with upper gastrointestinal bleeding at all times, including at night or weekends. We urge all providers and commissioners of care to use the toolkit to make their services as accessible, effective and safe as possible.
*See page 10 of the toolkit (available from the Academy of Medical Royal Colleges website)
Dr Tony Nicholson, Dean and Vice-President of The Royal College of Radiologists, said:
Upper gastrointestinal haemorrhage is most often a result of bleeding from ulcers in the stomach and duodenum but can occur from other causes, and has a high death rate if untreated. Up to the 1980s, surgery was the only treatment option. In the 1990s, endoscopes were perfected that could be used to stop bleeding, and in the 21st century, interventional radiology has developed techniques to stop bleeding where endoscopes have failed and also for stopping bleeding from causes other than ulcers.
There are big differences in outcome and survival of patients with upper gastrointestinal haemorrhage around the UK, with only a few hospitals able to offer treatment to rapidly treat bleeding by endoscopy or interventional radiology at any time of the day or night. This toolkit is the result of widespread consultation and recognition of best practice in hospitals around the UK. The lessons learned in providing endoscopy and interventional radiology services by those hospitals, and during the development of the toolkit, can now be used by all UK healthcare organisations to improve their standards, reducing complications and deaths from what is an eminently treatable condition.
- The toolkit and associated documents will be available free to download from the Academy of Medical Royal Colleges website.