Medical and surgical programme: half of patients with GI bleeds receive inadequate care, NCEPOD report finds

Published: 08 Sep 2015

Someone suffers a gastrointestinal bleed every 6 minutes, yet half of hospitals are not fully equipped to treat these patients

Someone suffers a gastrointestinal (GI) bleed every six minutes, but half of the hospitals that patients are admitted to as an emergency cannot provide all the services they need for a GI bleed, the latest report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has found. The national enquiry is calling for life saving 24/7 access to gastrointestinal bleed services allowing clinicians to start appropriate care and treatment plans as soon as the bleed is identified.

View full report here (pdf) >

Report co-author and NCEPOD Clinical Coordinator in Radiology Dr Simon McPherson explained that there are over 90,000 GI bleeds every year, yet there were still serious delays in recognising the condition: “This is the case even with the severe bleeds reviewed in this study, where patients received four or more units of blood.”

He explained that this had occurred in the cases of many existing inpatients, who accounted for a third of all the patient notes NCEPOD reviewed in Time to Get Control?

“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.”

Dr McPherson expressed concern that the report found many hospitals have no planning or procedures to bring together specialist advice and services rapidly for when a patient suffers a GI bleed: “It is unacceptable that some hospitals still don’t have a GI bleed service able to operate on-site or that has access to services as part of a network. Transferring patients to a hospital that has 24/7 endoscopy services is dangerous and places them at risk. We would like to see patients taken immediately to a hospital that can provide appropriate GI bleed services to minimise transfers.”

He also said that the study had highlighted that care for upper and lower GI bleeds was not consistent: “We have to be better at co-ordination of care and earlier input from senior clinicians. The traditional separation of upper and lower GI bleeds as different conditions needs to stop.” The NCEPOD study found that poor care had occurred not only out-of-hours, but also during normal working hours, unlike other healthcare conditions that are often affected by a reduced weekend service.

Report co-author and NCEPOD Clinical Coordinator in upper GI Surgery Mr Martin Sinclair said: “In all patients there is always a risk of a re-bleed and clinicians must consider this. In our study a quarter of patients (25.5%) with severe bleeds suffered a second bleed. Best practice indicates that all patients should have a re-bleed plan clearly recorded in their case notes.

“Our findings show that we are missing vital opportunities to reduce a patient’s stay in hospital, and improve their health outcome,” Mr Sinclair added.

Key findings:

  • Clinical care of 45% (214/476) of patients needed improvement
  • 32% (60/185) of hospitals admitting GI bleed patients did not have a 24/7 endoscopy service
  • 21% (35/170) of patients developing a GI bleed as an inpatient had delayed recognition of their GI bleed
  • 25.5% (138/595) of patients suffered a re-bleed
  • Organisational factors that lead to less than good care were identified in 18% (88/476) of cases
  • Blood product use was inappropriate in 20% (84/426) of cases. In 25% (113/457) improved management would have reduced the need for blood products
  • Only 18% (68/380) of patients had their care escalated to critical care, of whom 30 had undergone surgery
    44% (210/476) of patients received good care overall

Key recommendations:

  • Patients with any acute GI bleed should only be admitted to hospitals with 24/7 access to: on-site endoscopy; interventional radiology (on-site or covered by a formal network); on-site GI bleed surgery; and on-site critical care and anaesthesia
  • Hospitals that do not admit patients with GI bleeds must have 24/7 access to endoscopy, interventional radiology and GI bleed surgery for patients who develop a GI bleed as an inpatient for another condition.
  • This should be provided by either an on-site service or a formal network
  • The traditional separation of care for upper and lower GI bleeds in hospitals should stop. All acute hospitals should have a lead clinician responsible for local integrated care pathways for both upper and lower GI bleeding and their clinical governance. This should include identifying named consultants, ideally gastroenterologists, who would be responsible for the emergency and on-going care of all major GI bleeds
  • All patients who present with a major upper or lower GI bleed, either on admission or as an inpatient, should be discussed with the duty or on-call (out-of-hours) consultant responsible for major GI bleeds, within one hour of the diagnosis of a major bleed
  • The named consultant responsible for GI bleeds should direct the ongoing management of care for patients with a major bleed to ensure timely investigation and treatment to stop bleeding and reduce unnecessary blood transfusion
  • All patients with a GI bleed must have a clearly documented re-bleed plan agreed at the time of each diagnostic or therapeutic intervention

NCEPOD Chair Bertie Leigh warned that: “The problem of poor care for the very many patients who suffer a GI bleed must be addressed if it is not to become the next NHS scandal. Our detailed examination of GI bleed care and treatment reveals a situation of which we should be ashamed.

“It is essential that all hospitals have a Bleeding Rota to provide therapies at all times of the day or night, either on-site or as part of a network. But, the clinicians know that GI bleeding has just not been given the priority that this study shows it needs.”

He called on commissioners to “insist that the service patients and the public deserve is a priority and the CQC (Care Quality Commission) should look for evidence that the NCEPOD recommendations are being applied when they inspect”.