UGIB toolkit for a safer service

In response to increasing concerns about mortality rates and the standard of services across the country new guidance was produced earlier this year in the form of the “Consultant Rota On-call Modelling of Endoscopy Services” (CROMES) toolkit for the diagnosis and management of upper gastrointestinal bleeding (UGIB). The toolkit was commissioned by the National Patient Safety Agency (NPSA) and produced collaboratively by the Academy of Medical Royal Colleges, The Association of Upper GI Surgeons, the British Society of Gastroenterology (BSG), the Royal College of Nursing, the Royal College of Physicians and the Royal College of Radiologists. The toolkit will be of significance to those commissioning and redesigning healthcare services in a period of NHS change. The principles of better outcomes, patient-led services and clinical engagement, which run strongly through the toolkit, means that its recommendations are easily reconcilable with the restructuring of services under the health reforms, speak strongly to the QIPP agenda and pave the way for improved care and outcomes for UGIB patients. The toolkit was borne out of concerns for the current response to patients who present with UGIB, which were raised after audit data in 2007 revealed that each year in the UK, more than 50,000 patients develop acute gastrointestinal (GI) bleeding accompanied by a mortality rate of approximately 10%. For patients suffering from GI bleeding who have already been admitted to hospital, the mortality rate was shown to be as high as 25%. The most recent UK audit of UGIB undertaken by the National Blood Service and BSG in 2007, demonstrated that the prevalence of GI varices has more than doubled compared to 16 years ago, with the overall mortality rate not dissimilar to that of 60 years ago. Extensive audit has shown that the current provisions for UGIB services are often inadequately resourced and unsustainable.1-3 A range of treatments including endoscopy, interventional radiology, X-ray procedures and surgery can stop bleeding and save lives, and earlier use of these treatments leads to the achievement of better outcomes. However, in the UK almost 60% of patients are admitted outside of normal working hours, while almost half of hospitals do not presently provide these treatments out of hours. When coupled with a lack of clarity concerning the safe transfer of patients to referral centres, or other hospitals, where effective treatments are available, the significance of the need for an effective toolkit for local management was very apparent.

Developing service standards

 The National Institute for Health and Clinical Excellence (NICE) has also recognised the current service shortfalls and has recommended that “a national guideline is needed on the prevention and management of acute upper gastrointestinal bleeding to address the challenges posed by new interventions, and the uncertainties and variability in practice in primary and secondary care”.4 In specialist centres, where provision of the full range of therapeutic endoscopy and radiology services are available, both during the working week and out of hours (OOH), the reported morality rate is lower and there is an apparent reduction in the need for surgical interventions. As the NICE guideline goes through its development (which is expected to publish in July 2012) there is an urgent need to establish clear and simple routes to provide similar care to that accessible in specialist centres. The CROMES project has provided the guidance required to ensure outcomes for patients in all localities are reflective of those in specialist centres, so that wherever patients access treatment for UGIB, they can do so on a 24/7 basis. The objective of the project was, therefore, to enable and assist NHS organisations in establishing formal and robust arrangements to care for emergency patients in their locality presenting with UGIB 24 hours a day, throughout the year. Rather than being another guideline for best practice, the CROMES toolkit has been designed to offer an instrument for hospitals and commissioners to utilise when redesigning services to attain the optimum outcomes for patients presenting with this common, life threatening problem. The toolkit takes into account the barriers faced by small rural service providers, demonstrating how patients, in certain cases, can be treated optimally with the aid of appropriate transfers to units where emergency haemostatic therapies can be provided. The report therefore encourages the creation of networks of services for UGIB patients, ascertaining the viability of a service design that would be available to all patients, wherever they access their care. CROMES concludes that active resuscitation, followed by timely therapeutic endoscopy, supplemented by a range of radiological interventions in selected cases and judicious use of specific drugs, produce the best outcomes. The toolkit outlines nine service standards covering six aspects of service design as follows: