You may be surprised to find how poorly prepared and staffed your local hospital is. Susan Mayor for the BMJ reports: Half of UK hospitals lack essential services for managing acute GI bleeds, inquiry finds (BMJ 2015;351:h3488 ) Gastrointestinal bleeds are not as common as they used to be but late diagnosis, poor management and lack of facilities are endemic and a “scandal in the making”.
Patients with acute gastrointestinal (GI) bleeds should be admitted only to hospitals with 24/7 access to endoscopy, interventional radiology, GI bleed surgery, and the critical care facilities needed to optimise their care, a UK inquiry has recommended,1 saying that half of hospitals currently managing these patients lack some of these services.
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) collected data on the care and outcomes of patients admitted to hospitals in England, Wales, Northern Ireland, the Isle of Man, Guernsey, and Jersey with GI bleeding in the four months from 1 January to 30 April 2013.
The inquiry analysed the care of 1077 of the 4780 patients with a severe GI bleed managed at 227 hospitals. NCEPOD peer reviewers assessed clinician questionnaires and case notes from 485 cases against evidence based guidelines and recommendations. The reviewers considered that just under half (44%; 210/476) of these patients had received good care on the basis of what they would have accepted from their own teams. They judged that the clinical care of 45% of patients needed improvement.
“The problem of poor case [management] for the very many patients who suffer a GI bleed must be addressed if it is not to become the next NHS scandal,” warned Bertie Leigh, chair of the inquiry. “Our detailed examination of GI bleed care and treatment reveals a situation of which we should be ashamed.”
Recognition that a GI bleed had occurred was delayed in 21% (35/170) of people who developed the problem as an inpatient. And just over 25% of all patients with a GI bleed (138/595) had a re-bleed.
Lack of recommended services for managing GI bleeds was identified as a problem in many hospitals. One third of hospitals admitting GI bleed patients (32%; 60/185) did not have a 24/7 endoscopy service. Intraoperative gastroscopy was unavailable in 18% of hospitals, and intraoperative colonoscopy was unavailable at 33% of hospitals.
More than two thirds (70%) of hospitals did not provide 24/7 embolisation of GI bleeding onsite, although 45% had a formal network to deal with this.
Only 59% (99/167) of hospitals submitting data to the inquiry had a clinical lead for upper GI bleeds, and 38% (57/151) of hospitals had a clinical lead for lower GI bleeds.
Simon McPherson, NCEPOD report coauthor and a clinical coordinator in radiology, said, “Recognising and treating GI bleeds as quickly as possible can be more urgent than caring for a patient with a serious heart condition. The sooner the GI bleed is recognised and the patient is seen by the specialist, the better. But, without 24/7 access to GI bleed specialists, delays in recognition and treatment will continue—and continue to put lives at risk.”
The inquiry has recommended that the traditional separation of care for upper and lower GI bleeding in hospitals should stop. Instead, it recommends that all acute hospitals should have a lead clinician responsible for local integrated care pathways for both upper and lower GI bleeding.