Acute upper gastrointestinal bleeding: provision of clinical cover for University Hospital Crosshouse. Standard operating procedure

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 Crosshouse (UHC)

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, melaena 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 are AUGIB lists available in Crosshouse Monday to Friday every afternoon. There are no AUGIB lists available at the weekend and patients may need to have their endoscopy deferred over the weekend. The exception to this would be upper GI endoscopy in theatre by consultant surgeon on call, for ongoing fresh haematemesis or haemodynamic instability, refractory to resuscitation measures in the UHC Upper GI Bleeding (UGIB) bundle.

In the event of a patient presenting with AUGIB:

1. The team responsible for patient care (‘parent specialty team’) will commence the UHC 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.
   1. If Glasgow-Blatchford (GBS) score is 0/1 then outpatient oesophago-gastro-duodenoscopy (OGD) can be considered as risk of significant bleed is low.
   2. 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 27713 at 0800 or as early as possible.
   3. Consent 
      1. Formal consent for upper GI Endoscopy is the responsibility of the Endoscopist.
      2. 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.
      3. 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:
   1. 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 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)
   2. Out of hours, please contact the surgical registrar on #3377 (baton page) who will advise on next appropriate actions in the out-of-hours period.
4. AUGIB Consultant of the Day will refer for urgent upper GI endoscopy in theatre via page 3006 including anaesthetic team page 2824 any patient presenting with upper GI bleeding and any of the following:
   1. Oxygen requirement
   2. 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.

Parent Specialty Team

The parent team should ensure the UHC 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. 

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.

On call Anaesthetic Team

Resident anaesthetic doctor, carrying page 3388, on for emergency theatre will receive and communicate to Consultant Anaesthetist details of haemodynamically unstable or hypoxic patients for urgent endoscopy in theatre. This team will contribute to resuscitation, assessment and shared decision making for these cases within one hour of referral. 

UHC Upper GI bleeding bundle (PDF)