4. Audit system
Research database
National survey
National clinical audits
Network
Data repository
Clinical registries
National clinical
databases
Clinical databases
Audit database
Clinical
administration
system
Surveillance system
5. IBD Standards
• Launched between Feb and
April 2009
• Copies sent to trust and Board
CEOs with the 2nd round IBD
Audit results
• Circulated to SHAs, Primary
Care Trusts, Local Health Boards
• Work to establish a political
lobby
7. Why?
Rockall 1993/4
Mortality 14% overall
33% in inpatients; 11% in emergency admissions
Endoscopy use variable
What has changed ?
Early identification of high risk patients
Therapeutic endoscopy
Drug use in AUGIB
And...
Blood transfusion in AUGIB – never audited
8. What were they looking for?
Changes in mortality
Is the Rockall score still useful
Impact of therapeutic endoscopy
Use and effect of blood transfusion
Is there a relationship between
service provision and outcome?
9. 257 UK hospitals invited
217 hospitals (84%)
8939 cases submitted
Prospective study
Web-based data entry
1090 insufficient data
1099 not UGIB
6750 analysed (76%)
10. 10% overall
Mortality
7% in those who had endoscopy
45% of deaths were in patients who did not have
endoscopy
Rockall
score
0-2 (1408)
3-5 (2204)
6-7 (942)
≥8 (435)
Expected Observed
deaths
deaths
(1993/4 risk)
2007
2
143
201
179
13
125
122
110
Relative risk
(95% CI)
7.6 (3.49 to 5.85)
0.9 (0.73 to 1.05)
0.6 (0.55 to 0.78)
0.6 (0.50 to 0.74)
11. Out of hours presentation
44% of hospitals do not have formal out of
hours rota for endoscopy
60% of patients present out of hours
19% of new admissions, 25% of inpatients
between midnight and 8am
(Not known for 14% of inpatients)
12. Service provision & mortality
40
OOH rota
35
No OOH rota
30
25
Mortality 20
15
10
5
0
0 to 2
3 to 5
6 to 8
Rockall score
>8
13. Facilities available in hospitals
admitting patients with AUGIB
100
80
60
15 sites
40
20
0
ICCU
HDU
AUGIB
unit
Radiology
Blood
transfusion
Risk adjusted mortality in these hospitals no
different to UK figure
14. Endoscopy services
58% of hospitals have daily emergency
endoscopy slot Mon-Fri
50% of patients having endoscopy had it
within 24 hours
Rockall score little impact on time to first
endoscopy
50% of score 3+ and 43% score 5+ waited more
than 24hours
15. Endoscopists
51% endoscopies performed by consultants
32% performed by trainees – 60% of these
unsupervised
56% of hospitals have formal OOH rota for
endoscopy
14% of OOH endoscopies - unsupervised trainees
WHAT CAN BE DONE?
16. All high risk patients with UGIB should be endoscoped within 24
hours, preferably on a planned list in the first instance.
For patients who require more urgent intervention either for
endoscopy, interventional radiology or surgery formal 24/7
arrangements must be available.
17. Timing of endoscopy
Offer endoscopy to unstable patients with severe acute
upper gastrointestinal bleeding immediately after
resuscitation.
Offer endoscopy within 24 hours of admission to all other
patients with upper gastrointestinal bleeding.
Units seeing more than 330 cases a year should offer
daily endoscopy lists. Units seeing fewer than 330 cases a
year should arrange their service according to local
circumstances.
NICE 2012
20. All patients with suspected UGIB should be properly assessed and risk scored on
presentation.
All patients should be resuscitated prior to therapeutic intervention.Time to
diagnostic or therapeutic intervention for your patients
All high risk patients with UGIB should be endoscoped within 24 hours, preferably
on a planned list in the first instance.
For patients who require more urgent intervention either for endoscopy,
interventional radiology or surgery formal 24/7 arrangements must be available.
21. Encourage providers to participate
34% Trusts participating
in less than 60% NCAs
2010
in 2011 fallen to 14% of Trusts
(Nossiter & Black , Brit J Healthcare Mgt 2011)
25. Risk standardised mortality ratios
Measure of difference between observed mortality
and expected from audit population
106 hospitals with OOH on call endoscopy
Median RSMR 0.85
83 hospitals without OOH on call endoscopy
Median RSMR 1.02
26. Characteristics of National Clinical Databases
•
•
•
•
•
•
Focused on health care/services
National coverage (achieved or intended)
Prospective
On-going
Recruit all patients or representative sample
Collect patient-level data
(Other clinical data collections exist but they don’t
meet these criteria eg national confidential
enquiries)
27. Why?
Rockall 1993/4
Mortality 14% overall
33% in inpatients; 11% in emergency admissions
Endoscopy use variable
What has changed ?
Early identification of high risk patients
Therapeutic endoscopy
Drug use in AUGIB
And...
Blood transfusion in AUGIB – never audited
29. The UK IBD Audit: Past,
Present and Future.
On behalf of UK IBD Audit
Steering Group
Dr Ian Arnott
UK IBD Audit Clinical Director
Consultant Gastroenterologist
Western General Hospital, Edinburgh, UK
31. National clinical audits in England (2012)
Clinical area
Number
Children (inc neonatal)
8
Adult acute & emergency care
10
Long term conditions
7
Surgery/interventional procedures
7
Renal disease
3
Cancer
4
Trauma
3
Psychological conditions/treatments
2
Blood transfusion
2