NHS Ayrshire & Arran guidelines
The purpose of this document is to delineate a clear pathway to definitive care for patients who present with the symptoms of Acute Upper Gastrointestinal Bleeding (AUGIB) at University Hospital Ayr (UHA).
Acute upper gastrointestinal bleeding: provision of clinical cover for University Hospital Ayr. Standard operating procedure
Warning
UGI Bleeding is a common medical emergency with a significant risk of mortality reported as between 7 and 14%. The risk of mortality is even greater in patients who develop AUGIB as a hospital inpatient.
AUGIB is defined as haematemesis, melena or coffee ground vomiting (CGV) in the absence of an alternate diagnosis (e.g. bowel obstruction).
Optimal AUGIB management involves early recognition and resuscitation followed by timely access to Oesophago-Gastro-Duodenoscopy (OGD).
There is only flexible provision of endoscopy for AUGIB available in UHA Monday to Friday by a locum consultant gastroenterologist. There are no AUGIB lists available at the weekend. Therefore haemodynamically stable patients may need to have their endoscopy deferred or be transferred to equivalent parent specialty at University Hospital Crosshouse while stable. Patients who are haemodynamically unstable despite resuscitation, directed by the UHA AUGIB Bundle, need to be assessed early for consideration of transfer to UHC. The exception to this would be out of hour’s upper GI endoscopy in UHA theatre by consultant surgeon on call, who may have the capability to provide upper GI endoscopy and endostasis for AUGIB.
In the event of a patient presenting with AUGIB:
1. The team responsible for patient care (‘parent specialty team’) will commence the UHA Upper GI Bleeding (UGIB) Bundle – see Appendix 1. Sections 1-4 must be completed and signed prior to transfer for endoscopy. A paper copy of the Bundle must accompany the patient for Endoscopy. Section 5 must be completed on return from endoscopy.
a) If Glasgow-Blatchford (GBS) score is 0/1 then outpatient OGD can be considered as risk of significant bleed is low.
b) If GBS =>2 then request an inpatient endoscopy to be undertaken by placing an UGI Haemorrhage Endoscopy request within PMS and then contacting the Endoscopy Department on extension 14240 at 0800 or as early as possible.
c) Consent
i) Formal consent for upper GI Endoscopy is the responsibility of the Endoscopist.
ii) Parent specialty team are responsible for providing the patient or their Welfare Power of Attorney (PoA) with the relevant information (EIDO leaflet from Athena) and discussing the procedure in advance.
iii) If an individual lacks capacity and an Adults with Incapacity (AWI) form is more appropriate then it is parent specialty responsibility to have this completed prior to transfer for endoscopy.
2. In the event that a patient has presented with haemodynamic instability the parent specialty team will implement the ‘Resuscitation’ measures described within the UGIB Bundle (i.e. resuscitation with crystalloid as required, blood products)
3. If the patient condition does not improve or deteriorates despite implementing appropriate resuscitation then:
a) In working hours (Mon-Friday 0900-1700), the parent specialty team will also make a direct referral by page to the Acute UGI Bleeding Consultant of the Day as defined in the UGIB(UHA) rota (see Rotawatch) via switchboard. This clinician will advise on the management of the patient, including the need for more urgent endoscopy even if this requires cancellation or postponement of other, less urgent clinical activity (e.g. outpatient clinic or ward round).
b) In working hours (Mon-Friday 0900-1700) in the situation when there is no Acute UGIB Consultant of the Day listed for UGIB(UHA), the parent specialty team senior doctor should contact the day time UHA critical care consultant (page #3907) and UHA general surgical team (page #1995). These teams will consider whether next day provision of urgent endoscopy at UHA and/or advise on need to transfer to the critical care unit in UHC. In which case the UGIB consultant of the day at UHC will be informed.
c) Out of hours, the parent specialty in UHA will contact the surgical registrar via switchboard and critical care resident doctor on (page #1000), who will co-ordinate transfer to UHC for unstable patients and patients thought to require out of hours OGD. If transfer is required then the on-call consultant anaesthetist and UGIB Consultant (identifiable in Rotawatch) will be required. This phone call should be made prior to patient transfer to UHC to discuss the case and ensure endoscopic approach appropriate. The patient will be transferred to UHC critical care in expectation they will go to theatre 4 for OGD and endostasis. The UHC UGIB Consultant is responsible for co-ordinating the UHC theatre and anaesthetic team to facilitate emergency OGD.
d) There is restricted laboratory availability on the UHA site. Emergency O negative blood is routinely available. Blood is cross-matched on site at UHA during laboratory hours or when the Major Haemorrhage Protocol is activated. Out of hours, blood is usually cross-matched in the emergency laboratory at UHC with blood products sent to UHA by taxi. Consideration of urgent transfer of the patient to UHC rather than awaiting blood products being made available on the UHA site may be appropriate. This will require a senior decision maker to be involved.
4. When available the AUGIB Consultant of the Day will refer for urgent upper GI endoscopy in theatre (page #1008) including anaesthetic team (page #1000) any patient presenting with upper GI bleeding and any of the following:
i) Oxygen requirement
ii) Haemodynamic instability despite appropriate resuscitation
When 4 ii) applies Consultant Gastroenterologist and on-call Anaesthetist will attend patient within 1 hour to confirm if theatre would be optimal environment and encourage a combined responsibility for shared decision making discussion with the patient using BRAN principles (Benefits, Risks, Alternatives, outcome of doing Nothing).
Standard processes should be followed to co-ordinate relevant parties (Endoscopist, Endoscopy nursing team, theatre space, anaesthetist, ward) with the aim of achieving endoscopy within Emergency Theatre at >6 but <24hours.
Appendix 2 provides a flowchart detailing process to be undertaken when a patient presents at UHA with an Upper GI bleed.
Parent Specialty Team
The parent team should ensure the UHA UGIB bundle has been followed (see appendix 1). Specifically ensuring sufficient IV access is obtained to facilitate necessary resuscitation, endoscopy requested via trakcare and by contacting endoscopy and if appropriate, liaising with the AUGIB consultant or on call surgeon. Related to consent parent specialty responsibilities include providing patient information and completion of AWI where relevant.
Consideration should also be given to the placement of the patient by the referring team. Instability, significant co-morbidity, or associated organ dysfunction should prompt the clinician to consider a higher level care.
If higher level care is required, the responsibility for patient care following this will be assumed by the parent specialty team.
AUGIB Consultant of the Day
AUGIB consultant of the day, specified on Rota Watch, will ensure they can be contacted directly by page to receive urgent referrals for haemodynamically unstable cases between 9am and 5pm. This clinician will advise on the management of such patients, including the need for more urgent endoscopy and be prepared to cancel or postpone less urgent clinical activity (e.g. outpatient clinic or ward round) to provide this.
AUGIB Consultant of the Day will refer for urgent upper GI endoscopy in theatre, any patient presenting with upper GI bleeding who is dependent on oxygen therapy or is haemodynamically unstable despite appropriate resuscitation. They will attend such patients within 1 hour.
Formal consent for Endoscopy is the responsibility of the Endoscopist, which in day time hours is the AUGIB Consultant of the Day.
Resident Anaesthetist (UHA)
Resident anaesthetic doctor, carrying page 1000, on for emergency theatre will receive and communicate to Consultant Anaesthetist details of haemodynamically unstable or hypoxic patients for urgent endoscopy in theatre in UHA. This team will contribute to resuscitation, assessment and shared decision making for these cases within one hour of referral.
Additional Responsibilities in absence of UGIB Consultant of the Day General Surgical Team
In the event where there is no available UGIB consultant of the day, the general surgeon will assess the patient and determine if urgent OGD is required. They will determine whether urgent endostasis is possible on the UHA site and if not whether transfer to UHC is required. If transfer is required, the general surgeon will advise whether diagnostic OGD is indicated prior to transfer. Where variceal bleeding is diagnosed then a Sengstaken tube may be considered as a temporising measure prior to transfer.
In the event of transfer of a haemodynamically unstable patient the general surgeon is responsible for referral to UGIB consultant of the day at UHC.
Critial Care / Anaesthetic Team
Patients referred with large volume AUGIB or who are haemodynamically unstable may require transfer to UHC if endostasis is not available on the UHA site. Such patients should be assessed and resuscitation commenced prior to transfer by emergency ambulance to UHC. If the patient remains haemodynamically unstable or has ongoing active bleeding, packed red cells should be administered to the patient during the transfer. This will require a clinician able to administer blood to travel with the patient. Otherwise, the patient can be transferred by paramedic “blue-light” ambulance.
The UHA critical care / anaesthetic team will contact the UHC critical care doctor to arrange admission bed.
NB patients who are not expected to survive should not be transferred but instead should be palliated in UHA.
