Guidelines for Good Practice in and Audit of the Management of Upper Gastrointestinal Haemorrhage

 [bib_ref] Value of a centralised approach in the management of haematemesis and melaena:..., Holman [/bib_ref] [bib_ref] Acute upper gastrointestinal haemorrhage in a district general hospital: audit of an..., Clements [/bib_ref] [bib_ref] Mortality in patients with haematemesis and melaena: a prospective study, Hunt [/bib_ref] [bib_ref] Acute upper gastrointestinal haemorrhage in a district general hospital: audit of an..., Clements [/bib_ref] [bib_ref] Management of upper gastrointestinal bleeding in a district general hospital, Madden [/bib_ref] [bib_ref] A study of the factors influencing mortality rates from gastrointestinal haemorrhage, Allan [/bib_ref] [bib_ref] Clinical findings, early endoscopy and multivariate analysis in patients bleeding from the..., Morgan [/bib_ref] [bib_ref] Clinical factors in the prediction of further haemorrhage or mortality in acute..., Clason [/bib_ref] [bib_ref] OMGE international bleeding survey, Morgan [/bib_ref] [bib_ref] Nature of the bleeding vessel in recurrently bleeding gastric ulcers, Swain [/bib_ref] [bib_ref] Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from..., Bornman [/bib_ref] [bib_ref] Non-steroidal antiinflammatory drugs and bleeding peptic ulcer, Somerville [/bib_ref] 

## Standards of practice
The following guidelines, applicable to all hospitals which accept emergency admissions, aim to provide a minimum standard against which existing practice and outcome may be judged. Report of a joint working group Admission arrangements Patients with acute upper gastrointestinal bleeding should be admitted (or transferred) to a safe environment. In many hospitals this will be an acute general medical ward where the staff has experience of the problem. Severely ill patients are best admitted to a high dependency unit, defined as an area for patients who require more intensive observation and/or nursing than would be expected on a general ward. Critically ill patients, particularly those with very rapid bleeding, those with severe coincidental cardiorespiratory, hepatic or renal disease, and those with bleeding oesophageal varices, may require admission to an intensive care unit if they need invasive monitoring, mechanical ventilation or other treatment for organ failure.
Some hospitals admit all patients with upper GI bleeding to beds designated for treatment of gastroenterological disorders; such units are often jointly managed by medical and surgical staff with an interest in the specialty. A patient who needs surgical treatment is often best treated in the same ward before and after operation to preserve continuity and facilitate joint surgical and medical management.

## Blood transfusion
A hospital which accepts patients with acute upper GI haemorrhage should provide a 24-hour blood transfusion service, preferably one which is part of the National Quality Control Scheme. The laboratory should keep a supply of Group O Rh-blood for emergency use.

## Endoscopy
Facilities should be available for upper gastrointestinal endoscopy within 24 hours of admission. A rota should be maintained of endoscopists trained both in diagnosis and therapeutic measures to check bleeding. It may be possible in some circumstances for endoscopists in different but neighbouring hospitals to cover for one another, an arrangement which also permits interchange of experience. The procedure should be performed in a fully equipped endoscopy unit staffed by nurses trained in the care of ill patients during endoscopy and in the maintenance and use of the instruments and accessories. The staff should be aware of the particular danger of pulmonary aspiration in these patients and trained to deal with unexpected vomiting. Facilities should be available for cardiorespiratory monitoring during and after endoscopy [bib_ref] Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy, Bell [/bib_ref]. It is important to resuscitate adequately and in particular to correct hypovolaemia before endoscopy. Sedation may be hazardous in these ill patients [bib_ref] Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy, Bell [/bib_ref]. In a patient whose consciousness is already impaired owing, for example, to hepatic encephalopathy, endotracheal intubation may be necessary to protect the airway. Occasionally patients may need endoscopy out of normal working hours or in the operating theatre (or anaesthetic room); arrangements for such contingencies should be prepared.

## Planning
Medical, surgical and nursing staff should together draw up an agreed protocol for the management of patients with upper gastrointestinal haemorrhage. Once prepared, copies of this protocol should be given to all medical and senior nursing staff who care for such patients, the admission department, all medical (including geriatric) and surgical wards, departments such as the laboratory and pharmacy, and the hospital management team.

## Records
The system of hospital coding used should identify patients with acute upper gastrointestinal haemorrhage, whatever the cause, in all departments of the hospital. The code for bleeding peptic ulcer has been defined separately only in the 9th revision of the International Classification of Disease. The advent of ICD10 and the development of Read codes should make coding more specific. Endoscopy and theatre records, both of which are often computerised, may be used to 'flag' patients with bleeding. The protocol for management of bleeding should lay down the form of clinical record to be maintained.

## Management (see also flow charts)
The management of acute gastrointestinal haemorrhage is summarised in the accompanying flow charts (pp283 and 284). In addition, the admitting physician or surgeon can consider the following points. [bib_ref] Central venous pressure in clinical management of acute gastrointestinal bleeding, Northfield [/bib_ref]. Packed red cells may be needed if there is anaemia but a normal or increased blood volume.
What is the source of bleeding?
? The likely source of bleeding may be suspected on clinical grounds, particularly if there is a history of peptic ulcer or evidence of liver disease. Upper GI endoscopy, performed within 24 hours of bleeding, can identify the site of bleeding in most cases. Patients with slight bleeding who are haemodynamically stable may be endoscoped within 48 hours on the next routine list, if necessary as outpatients, though this reduces the likelihood of making a diagnosis. If bleeding is severe, and especially if continued, then early endoscopy is indicated and the endoscopist should take an active part in clinical care. The endoscopist is responsible for assessing the possible hazards of the procedure for each patient and seeing that precautions are taken to avoid them as far as possible (see above).
? Diagnostic endoscopy without a therapeutic procedure does not affect mortality [bib_ref] Outcome of endoscopy and barium radiography for acute upper gastrointestinal bleeding: controlled..., Dronfield [/bib_ref] [bib_ref] Why have controlled trials failed to demonstrate a benefit of oesophago-gastro-duodenoscopy in..., Erickson [/bib_ref] , though in most cases it is possible to define the source of bleeding. Detection of active bleeding or of a visible vessel with-out bleeding gives information about the likelihood of continued or recurrent bleeding. A spurting arterial bleeding point indicates major continued bleeding. A visible vessel, defined as a red or blue spot elevated from the base of an ulcer, or a protruding clot in the base of an ulcer, are both associated with about double the usual risk of re-bleeding [bib_ref] Nature of the bleeding vessel in recurrently bleeding gastric ulcers, Swain [/bib_ref]. The combination of a visible vessel and hypotensive shock is associated with an 80% chance of re-bleeding [bib_ref] Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from..., Bornman [/bib_ref]. Oozing of blood from the floor of an ulcer crater, or a red or black spot level with the floor of an ulcer are signs of recent haemorrhage but do not indicate an above average risk of re-bleeding. In the absence of any sign of recent bleeding from an ulcer, re-bleeding is most unlikely [bib_ref] Nature of the bleeding vessel in recurrently bleeding gastric ulcers, Swain [/bib_ref] [bib_ref] Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from..., Bornman [/bib_ref].
? The main reason for determining the site and activity of bleeding is to assess suitability for endoscopic treatment of a visible vessel in an ulcer or vascular malformation, or of a ruptured varix complicating portal hypertension. Information about the site of bleeding may also assist the surgeon if operation is required.
What medical or endoscopic measures should be taken to stop bleeding or reduce the risk of early recurrent bleeding?
? If a bleeding peptic ulcer is found on endoscopy, there is no unequivocal evidence that immediate drug therapy reduces mortality. Although meta-analysis has suggested that antifibrinolytic therapy and gastric antisecretory drugs could reduce mortality [bib_ref] Effects of fibrinolytic inhibitors on mortality from upper gastrointestinal haemorrhage, Henry [/bib_ref] [bib_ref] Treatment with histamine H2 antagonists in acute upper gastrointestinal haemorrhage: implications of..., Collins [/bib_ref] , large scale clinical trials have failed to confirm the value of antisecretory drugs [bib_ref] Omeprazole v placebo for acute upper gastrointestinal bleeding: a randomised double blind..., Daneshmend [/bib_ref] [bib_ref] Randomised double blind controlled trial of intravenous famotidine infusion in 1005 patients..., Walt [/bib_ref] , and antifibrinolysis requires similar study before it can be generally accepted.
? If an ulcer with a visible vessel in its base is found, two general methods of endoscopic haemostasis are available?thermal coagulation and direct injection of a vasoconstrictor and/or sclerosant. Since the mortality from bleeding peptic ulcer is low, only a few studies have shown a significant reduction in death rate [bib_ref] Controlled trial of Nd-YAG laser photocoagulation in bleeding peptic ulcers, Swain [/bib_ref]. However, a meta-analysis of 25 randomised controlled trials using different methods has suggested a significant reduction of about one-third in the death rate [bib_ref] Endoscopic haemostasis. An effective therapy for bleeding peptic ulcers, Sacks [/bib_ref]. Several controlled trials have shown improvement as compared with a control group for such endpoints as frequency of re-bleeding or need for urgent surgery, transfusion requirement and number of days in hospital [bib_ref] Endoscopic haemostasis for non-variceal upper gastrointestinal haemorrhage, Steele [/bib_ref]. Trials are difficult to conduct and patients need to be stratified according to the nature and activity of the bleeding point. What the optimum method of treatment should be is not yet clear and may not be critical. Controlled trials are in progress of injection therapy with adrenaline, with or without a sclerosant, and of thermal treatment with or without injection therapy [bib_ref] Bleeding peptic ulcers, Bown [/bib_ref]. Repeat treatment may sometimes be indicated. It seems likely that endoscopic treatment of bleeding peptic ulcer, using generally ? There is evidence from a controlled trial that a policy of early operation reduces mortality among patients over 60 years of age but that early surgery in younger patients leads to unnecessary operations [bib_ref] Optimal timing of operation for bleeding peptic ulcer: prospective randomised trial, Morris [/bib_ref] which may increase mortality in duodenal ulcer [bib_ref] Conservative management of bleeding duodenal ulcer without a visible vessel: prospective randomized..., Saperas [/bib_ref]. ? If a patient aged >60 years or a younger patient with any high risk factor requires more than four units of whole blood to restore or maintain blood volume over 24 hours or continues to bleed or re-bleeds, operation is generally advised. ? If a patient aged >60 years without any high risk factor continues to bleed or shows evidence of two episodes of re-bleeding, operation is generally advised. [bib_ref] Apache II score in massive upper gastrointestinal haemorrhage from peptic ulcer: prognostic..., Schein [/bib_ref].
? If a patient with bleeding peptic ulcer has been previously fit, but with a history of recurrent ulcer-type dyspepsia, and is not severely ill from the bleed, a definitive operation for peptic ulcer may be indicated, usually Billroth I partial gastrectomy for gastric ulcer or truncal vagotomy and pyloroplasty for duodenal ulcer.
? If a patient with bleeding peptic ulcer is elderly and in poor physical condition, the minimum operation to stop the bleeding should be undertaken, either by local excision or under-running of a gastric ulcer [bib_ref] Late outcome of undersewing alone for gastric ulcer haemorrhage, Teenan [/bib_ref] or under-running of a duodenal ulcer. ? If variceal haemorrhage is uncontrollable by the means described above, and provided that liver function is adequate, distal oesophageal transection and reanastomosis with ligation of veins around the distal oesophagus and gastric fundus is usually the best option. ? If a patient is bleeding from gastric carcinoma, the lesion is usually advanced. Polya gastrectomy may be appropriate for distal tumours but total gastrectomy for proximal tumours is not appropriate as an urgent procedure [bib_ref] Acute haemorrhage from gastric malignancy, Allun [/bib_ref].
Follow-up and drug treatment ? If the patient is anaemic, oral iron should be given until the haemoglobin level returns to normal. ? If a peptic ulcer is found, treatment should be given to heal the ulcer.
? If the ulcer is in the stomach, repeat endoscopy with biopsy is indicated after 6-8 weeks to check that it is benign.
? If the patient is elderly and frail, re-bleeding from an ulcer could be fatal. The cumulative risk of another bleed is about 16% at 5 years [bib_ref] The late results of medical and surgical treatment for bleeding duodenal ulcer, Harvey [/bib_ref] [bib_ref] Late outcome of bleeding gastric ulcers, Smart [/bib_ref]. There is some evidence that long-term H2 blocker therapy reduces the rate of recurrent bleeding in patients with duodenal ulcer [bib_ref] Maintenance ranitidine treatment after haemorrhage from a duodenal ulcer, Murray [/bib_ref] [bib_ref] Randomized controlled study of ranitidine maintenance for patients with a recent severe..., Jensen [/bib_ref]. Long-term treatment of elderly patients with a gastric antisecretory drug should therefore be considered. If the patient is young and fit, long-term treatment is determined by the severity of ulcer symptoms. Patients with frequent recurrent ulcer dyspepsia require long-term maintenance therapy; those with infrequent mild symptoms can be treated intermittently with an H2 blocker. In future, proton pump blockers and treatment to eliminate Helicobacter pylori may be used for some patients. ? If the patient has taken nonsteroidal anti-inflammatory drugs, this treatment should preferably be stopped. If they are essential, then addition of an H2 blocker for duodenal ulcer [bib_ref] Prevention of gastroduodenal damage induced by non-steroidal anti-inflammatory drugs: controlled trial of..., Ehsanullah [/bib_ref] or synthetic prostaglandin for gastric ulcer [bib_ref] Prevention of NSAIDinduced gastric ulcer with misoprostol: multicentre, doubleblind, placebo-controlled trial, Graham [/bib_ref] The general practitioner needs information about the diagnosis and treatment in hospital at least by the day on which the patient is discharged. ? If the general practitioner is asked to undertake responsibility for follow-up, repeat blood tests or drug treatment, a plan of management should be suggested.
Audit of structure, process and outcome Medical care can be considered in terms of structure, process and outcome [bib_ref] Evaluating the quality of medical care, Donabedian [/bib_ref]. Structure is concerned with the amount and type of resources available. Process relates to the amount and type of activity expended in the care of the patient. Outcome in the case of upper gastrointestinal haemorrhage is concerned primarily with mortality and secondarily with patient satisfaction. Answering the following questions will reveal breaches of the protocol drawn up by the hospital staff, and its deficiencies. Revision of the protocol as a result of this analysis combined with an assessment of outcome, and regular re-evaluation with further change as necessary, closes the audit loop. ? If a patient was at high risk because aged >60 years, or systolic blood pressure clOOmm Hg or postural fall, or HbclOG, or complicating disease, was the protocol followed in the following respects? admission to high dependency ward or equivalent consultant physician and consultant surgeon informed early endoscopy (within 24 hours) performed ? If a patient was aged <60 years, was physically fit, not shocked or anaemic, and did not re-bleed within 4 days, was admission to hospital <5 days, was a diagnosis made, and was a plan for further management made? ? If a patient was shocked, was correction of circulating volume commenced without delay and was blood transfusion begun within 2 hours? ? If a patient was shocked or required transfusion in the presence of severe cardiorespiratory disease, was a central venous pressure line inserted, and was monitoring of venous pressure satisfactory? ? If a recently bleeding vessel in an ulcer base or if a bleeding oesophageal varix was found on endoscopy, was endoscopic treatment undertaken? ? If a patient at high risk (see above) required more than 4 units of blood in 24 hours to maintain blood volume or re-bled, was surgery considered?
? If a patient aged <60 years who was in previous good health showed evidence of continued bleeding or rebled twice, was surgery considered?
? Was the decision for surgery made by a consultant surgeon and was a consultant anaesthetist informed?
? If a patient required surgery, was pre-operative preparation and post-operative care satisfactory? ? Is there evidence, from the notes, of good communication with the patient, relatives and general practi- [bib_ref] The report of a confidential enquiry into perioperative deaths. London: Nuffield Provincial..., Buck [/bib_ref]. Possible audit questions after a death are listed in Appendix B.
Possible multicentre therapeutic trials Since overall mortality is 10% or less, controlled trials have to be large, about 2,000 patients, to have sufficient power to detect with confidence any change in death rate. Smaller numbers in a trial may give significant results without loss of power if a subset of patients (eg over 60 years, visible vessel in a peptic ulcer, oesophageal varices) with a relatively higher mortality is studied. A factorial design would increase the information gained. The following items of information should be clearly stated in each clinical record. Their presence or absence is a measure of the quality of the record. Ideally, the information could be recorded during admission using a special proforma for use whenever a patient with upper gastrointestinal haemorrhage is treated, so that not only the presence or absence of the data but also the actual data are readily visible. Why was a decision made for or against surgery?
Was the interval to, and timing of, surgery a factor in the outcome?
Was the operation appropriate?
[table] tioner ? ?: Is there evidence, from the clinical record, of an adequate follow-up plan? Audit questions on outcome (a) For a hospital ? What is the outcome for all patients treated in the hospital for acute upper GI haemorrhage? number discharged with residual complication (eg stroke) arising during admission number who died (and certified cause of death) If comparison between hospitals is made, then casemix severity, including age, cause of bleeding and comorbidity, will need to be taken into account. (b) For individual patients ? Complications during admission ? Days in hospital ? Discharge well or with residual complication ? Death ? Was any complication or death avoidable? ? Were the patient and relatives satisfied with the care received? Possible national audit A confidential enquiry into deaths from acute upper gastrointestinal haemorrhage could be set up along the lines of the CEPOD study [/table]