Do the Regional Upper GI Bleed Services can provide safe and effective services? (Outcome based analysis from a regional upper GI bleeding service centre in the United Kingdom)

doi:10.21203/rs.3.rs-4940852/v1

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Do the Regional Upper GI Bleed Services can provide safe and effective services? (Outcome based analysis from a regional upper GI bleeding service centre in the United Kingdom)

https://doi.org/10.21203/rs.3.rs-4940852/v1

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Background

The aim of this study was to compare the clinical characteristics and clinical outcomes of patients who presented with AUGIB among two groups of patients who were transferred from local and district hospitals for endoscopy and subsequent management versus direct admissions to the emergency department with acute UGIB to the Sheffield University Hospital NHS Trust.

Methods

We included 259 patients who underwent upper GI endoscopy from April 2018 to March 2022, of whom 29 were transferred and 230 were direct admissions. The analysis focused on demographics, pathological findings, and time to endoscopy, blood transfusions, and hospital stay.

Results

Transferred patients were younger (median age 58 vs. 67 years) and received early endoscopic interventions compared to direct admissions (mean time to endoscopy 0.97 vs 2.1 days/p = 0.001). The means (s.d.) of hospital stay among the transferred and direct admission groups were 9.9 (9.5) and 8.3 (9.7) days, respectively (p = 0.43), regardless of intervention timing or transfusion needs. The timing of the procedure did not influence the length of hospital stay from the time of endoscopy to discharge (p = 0.241). Thirty-day mortality was 8 (28%) in the transferred group and 20 (9%) in the non-transferred group. (p = 0.006)

Conclusion

These findings underscore that regional bleeding services are safe and effective.

Endoscopy

upper GI bleeding

Regional bleed service

Emergency services should have access to 24/7 endoscopy to look after patients presenting with upper GI bleed. However, challenges exist in providing these services in peripheral hospitals which does not have round the clock services.. We found that the regional upper GI bleed service may be safely and effectively carried out and services should ensure that a sustainable practice prevails by having policies and job planning arrangements in place.

Acute upper gastrointestinal bleeding (AUGIB) represents a significant medical emergency, with a presentation rate of one every six minutes in the United Kingdom and an annual incidence of 134 cases per 100,000 people. () Despite advancements in medical care, the mortality rate among new admissions with AUGIB in the UK was 7%, while among inpatients in 2007, it was 26%. () Recent data indicate an increasing trend in mortality rates among the US population in 2021 compared to the period from 2012 to 2019, highlighting the ongoing challenges and the need for improved management strategies for AUGIB. ()

Substantial initiatives have been undertaken to enhance both the clinical and organizational management of patients with AUGIB. The evidence concerning early endoscopy has been contentious, as certain studies have indicated that early intervention through endoscopy may not alter outcomes. () However, more recent research has proposed that early endoscopy could lead to reduced resource utilization, enhanced patient outcomes, and decreased mortality rates. ()

The current consensus acknowledges that the optimal standard of care for AUGIB should involve round-the-clock access to specialists in endoscopy, interventional radiology, and surgery. (,). Ninety percent of the hospitals provide out-of-hours (OOH) onsite endoscopy services according to the British Society of Gastroenterology (BSG) upper GI bleeding audit in 2022, which is low in comparison to the audit in 2007 (92%). () According to the BSG/NHS England National Survey in 2014–2015 on the provision of OOH services for acute AUGIB in England, 80% of hospitals offer 24/7 endoscopy services for unstable patients, and an additional 10% are part of networks providing acute services; only 60% perform endoscopies within 24 hours for stable acute admissions or inpatients with AUGIB in the UK. These statistics have shown minimal changes since the last audit in the UK in 2013, with 77% providing OOH services and 56% conducting endoscopies within 24 hours. ()

Some hospitals have set up their own way of providing care by setting up methods such as inter-hospital transfer methods for acute management of AUGIB and have shown that regional bleeding services are effective and safe. ()

Sheffield University Hospital Trust provides 24/7 acute upper GI bleeding services directly to its emergency department attendees with an on-call gastroenterologist. In addition, they provide 24/7 regional UGIB services to three of the region’s hospitals as a goodwill arrangement but are not commissioned and it does not have a policy on referral criteria as well. These three hospitals provide acute UGIB services during the daytime but not after hours 17.00 on week days and on weekends/holidays. This is the first ever evaluation of regional UGIB services in the UK.

The aim of this study was to compare the clinical characteristics and to assess the clinical outcomes of patients who presented with AUGIB among two groups of patients who were transferred from regional district general hospitals for endoscopy and subsequent management versus direct admissions to the emergency department with acute UGIB to the Sheffield University Hospital NHS Trust.

This was a retrospective analysis of the data of patients who were referred for the management of AUGIB, mainly for endoscopy, to the Sheffield University Hospital NHS Trust from April 2018 to March 2022. We also matched the data of all the patients who were directly admitted to the emergency department with AUGIB during the same time period. Patient electronic data were accessed to determine the basic characteristics, pathological diagnosis, time to endoscopy, and 30-day mortality. Statistical analysis of the collected data was performed using SPSS version 20 (SPSS Inc., Chicago, IL, USA) to compare the above findings with t tests and chi-squared tests.

There were 29 patients who transferred and 230 patients who were directly admitted to AUGIB to the two hospitals of trust during the time period. Table 1 compares the basic characteristics, timing of endoscopy, and number of blood transfusions following admission and length of stay between the two groups.

Table 1

Comparison of basic characteristics, timing to endoscopy, blood transfusions following admission and length of stay between the two groups
		Transferred group (n = 29)	Non Transferred group (n = 230)	Significance
Age (years) median (25th -75th Percentile)		58(51.2–66.8)	66.6 (64-69.2)	p = 0.037 (independent sample t test)
Gender	Males	14 (48%)	154(58%)	p = 0.42 (Chi-squared test)
	Females	15 (52%)	56 (42%)
Timing of the endoscopy
	< 12 hours	9(31%)	56(24%)
	12–24 Hours	6(21%)	73(32%)
	24–48 hours	1(3%)	70(30%)
	> 48 hours	7(24%)	31(14%)
	Not done	6(21%)	0()
	Mean (s.d.) hours	0.97(1.4)	2.1(3.1)	p = 0.001 (independent sample t test)
Blood transfusion
	0	24	121
	1 to 2	5	71
	> 3	0	38
Length of stay (days)
	25th Percentile	4	3
	50th percentile	7	5
	75th Percentile	16.5	10
	Mean(s.d.)	9.9 (9.5)	8.3 (9.7)	0.43 (independent sample t test)
30 day mortality		8 (27.6%)	20 (8.7%)	p = 0.006 (independent sample t test)

Table 1 presents a comparison between two groups: the "Transferred group" and the "Non-Transferred group". This analysis highlights significant differences in age, timing of intervention, and blood transfusion requirements between the Transferred and Non-Transferred groups, with a tendency toward more expedited endoscopy and less blood utilization in the Transferred group. However, the length of hospital stay did not show a notable difference between the groups. The 30-day mortality rate was greater in the transferred group. (p = 0.006)

Table 2

Diagnosis made via endoscopy
Pathology	Transferred group		Nontransferred group
Pathology	n	%	n	%
No	5	17.2	73	31.7
Ulcer/gastric or duodenal	4	13.8	64	27.8
Severe Oesophagitis	2	6.9	18	7.8
Varices	7	24.1	16	7.0
PGH	0	0	11	4.8
Mallory Weiss tear	0	0	10	4.3
Angiodysplasia	0	0	7	3.0
Altered blood	0	0	6	2.6
Erosive gastritis	1	3.4	6	2.6
Duodenal tumour	0	0	4	1.7
Leiomyoma	0	0	3	1.3
Dieulafoy’s	0	0	2	0.9
Oesophageal polyp/lesion	0	0	2	0.9
Gastric bypass bleed	0	0	2	0.9
GAVE	0	0	1	0.4
Gastric varices	1	3.4	1	0.4
Duodenal fistula	0	0	1	0.4
GIST	0	0	1	0.4
Post oesophageal EMR	0	0	1	0.4
Sphincterotomy bleed	0	0	1	0.4
Banding ulcers	2	6.9	0	0.0
PEG site bleeding	1	3.4	0	0.0
No scooping done	6	20.7	0	0.0
Total	29	100	230	100.0

Table 2 highlights notable differences in the distribution of various pathologies between the Transferred and Non-transferred groups. The Transferred group exhibited a greater prevalence of varices and certain other pathologies than in the Non-transferred group. Understanding these differences can provide insights into the characteristics and clinical profiles of patients requiring transfer versus those managed within the same facility.

A significant percentage (n = 6/20.7%) of patients in the transferred group and the non-transferred group were not scoped. Among them, two patients were directly examined with small bowel video capsular endoscopy, one patient who worsened during endoscopy and died (those with decompensated cirrhosis and frailty), one patient who was offered TIPPS, and two patients who did not need scoping. The details of the patients who died after being transferred for acute UGIB are described in Table 3.

Table 3

Patient details who died after transfer for management of acute UGIB
Age	Gender	Co morbidities	Duration to endoscopy	Intervention	Time to death since admission
(years)	Gender	Co morbidities	Duration to endoscopy	Intervention	Time to death since admission
65	Male	CLCD, Renal failure, Variceal bleeding with banding ulcers	3 Hours	DANIS stent and TIPPS (day 5)	Day 12
80	Female	Congestive cardiac failure and atrial fibrillation on long term anticoagulation, after ERCP	9 hours	Found to have a large clot over the papilla, clot removed.	Day 1
43	Male	ARLD with decompensated cirrhosis and chronic pancreatitis.	Not done	Patient was not stable for UGIE. Hb was 44	Day 4
89	Female	AF and heart failure and diabetes mellitus, and on long term anticoagulation	Not done	Small bowel capsular endoscopy planned/but not done	Day 4
62	Female	ARLD, acute renal failure, septicaemia and shock.(DNA-CPR)	8 days	Varices banding	Day 10
59	Male	ARLD and decompensated cirrhosis	12 hours	Rescoped in 2 days due to continuous malena and dropping Hb. Scoped with paediatric colonoscope duodenitis. No intervention done.	Day 6*
79	Female	Chronic kidney disease, ischemic heart disease with CAGB 3 times had an ERCP for cholangitis	Not done	Angiographic intervention was done for duodenal bleeding on day 3	Day 20
62	Male	Large mediastinal non-Hodgkins lymphoma and COPD, pulmonary embolism and acute copulmonale. Suspected small intestinal bleed	Not done	Small bowel capsular endoscopy and vascular angiography done on 11th day	Day 18
*COD- Multi-organ failure and spontaneous UGIB

This study highlights that regional bleeding services are safe and effective. This is the first study to illustrate a regional UGIB service in the UK. This has illustrated that a safe and effective service can be delivered if there is a willing and keen clinical team in the larger receiving hospital. The service provided is not commissioned or job planned for the consultants at the tertiary centre; However, these arrangements are likely to be sustainable if they are job planned to make the service may be more sustainable in the long term if regional services needed to be provided. This will minimise the risk of burn out too..

Based on an agreed-upon transfer policy, when a local gastroenterologist service is unavailable, patients were transferred from the DGHs to the accident and emergency services at the Northern General Hospital site, where they were reassessed by the emergency care team in conjunction with the gastroenterologist on call. The comparison between transferred and non-transferred patients undergoing endoscopy for acute upper gastrointestinal bleeding revealed important differences in demographic and clinical characteristics, with implications for patient care and outcomes. Patients in the transferred group were significantly younger than those in the direct admissions group. The finding that the median age was lower in the Transferred group aligns with prior research indicating that younger patients may experience more acute or severe episodes of upper gastrointestinal bleeding that necessitate transfer for specialized care. () However, one study showed that elderly people have a greater mortality rate than young people due to co morbid conditions and anticoagulation. () Although there was no statistically significant difference in sex distribution between the groups, underlying co morbidities may still play a role in the clinical presentation and management of acute upper gastrointestinal bleeding. ()

The observed promptness of intervention in the transferred group aligns with guidelines emphasizing early endoscopic intervention for acute upper gastrointestinal bleeding to improve outcomes and reduce mortality rates. () At the same time, it seems that those patients required fewer transfusions. It is likely that the transferred patients had been transfused as part of the initial resuscitation plans locally (data not available) which explains the lower transfusion rates. The lower blood transfusion requirements in this group could also reflect more effective early management and targeted interventions to control bleeding sources.

Although there was no significant difference in hospital stay between the two groups, the higher mean number of days and 75th percentile in the transferred group indicate that hospital stay is clinically important and affects the bed occupancy of the tertiary centre. The 30-day mortality rate was greater in the transferred group than in the non-transferred group, which can be explained by greater co morbidities. This is mostly apparent in the co morbidity profiles of the patients who died within 30 days.

There is also concern that clinical and nursing teams at hospitals may become deskilled if OOH upper GI bleeding services are not available. Although only a small percentage of patients may need a scope immediately after resuscitation, not having an OOH endoscopy service in the DGHs makes immediate endoscopy within 2 hours of optimal resuscitation impossible. (NCEPOD recommendation)

There are several limitations of the study; these include a lack of information related to the care given at the base hospitals prior to transfers, such as medications or transfusions administered. We do not have the details of patients who were not transferred due to clinical reasons such as being unfit for transfers.

This has illustrated that a safe and effective service can be delivered if there is a willing and keen clinical team in the larger teaching hospitals. Since the services are currently run by goodwill arrangement, policy based arrangement is recommended.

Funding

No funding

Author Contribution

SB, JS and CS involved in planning, data collection and initial analysisNN involved in data analysis, writing and drafting the final manuscriptMT done the supervision at all the levelsAll authors approve the final version of the manuscript.

Acknowledgements

Not applicable

Availability of data and materials

;The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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No competing interests reported.

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Do the Regional Upper GI Bleed Services can provide safe and effective services? (Outcome based analysis from a regional upper GI bleeding service centre in the United Kingdom)

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Abstract

Background

Methods

Results

Conclusion

Key Message

Introduction

Objectives And Methods

Results

Discussion

Conclusions

Declarations

Funding

Author Contribution

Acknowledgements

Availability of data and materials

References

Additional Declarations

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