Quality statement 2: Immediate endoscopy for people who are haemodynamically unstable

Quality statement

People with severe acute upper gastrointestinal bleeding who are haemodynamically unstable are given an endoscopy within 2 hours of optimal resuscitation.

Rationale

In most cases, endoscopy diagnoses the cause of bleeding, provides information about the likely prognosis and facilitates delivery of a range of haemostatic therapies. People who are haemodynamically unstable should be given an endoscopy within 2 hours of optimal resuscitation because their condition means they need urgent investigation and treatment.

Quality measures

Structure

Evidence of local arrangements to ensure that people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable are given an endoscopy within 2 hours of optimal resuscitation.

Data source: Local data collection.

Process

Proportion of people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable who receive endoscopy within 2 hours of optimal resuscitation.

Numerator – the number of people in the denominator who receive endoscopy within 2 hours of optimal resuscitation.

Denominator – the number of people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable.

Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: initial management (NICE clinical guideline 141).

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable to be given an endoscopy within 2 hours of optimal resuscitation.

Healthcare practitioners perform an endoscopy within 2 hours of optimal resuscitation in people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable.

Commissioners ensure that they commission services that give an endoscopy within 2 hours of optimal resuscitation to people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable.

What the quality statement means for patients, service users and carers

People with severe acute upper gastrointestinal bleeding whose blood pressure and/or pulse is unstable are given an endoscopy (a procedure using a narrow, flexible tube that is swallowed and has a very small camera at its tip) within 2 hours of being resuscitated.

Source guidance

  • Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendation 1.3.1 (key priority for implementation).

Definitions of terms used in this quality statement

2 hour timeframe Derived from expert consensus.

Haemodynamically unstable People who are haemodynamically unstable are those with active bleeding whose blood pressure or pulse cannot be normalised or who need rapid intravenous fluids to maintain haemodynamic stability.

Endoscopy is associated with complications. These are uncommon when it is used for diagnosis in relatively fit people, but are relatively common in people who are actively bleeding, and may be life threatening in people with comorbidities whose condition is unstable.

The full guideline Acute upper gastrointestinal bleeding: management states that, whenever possible, endoscopy should not be undertaken until cardiovascular stability is achieved. However, it is recognised that for people who are haemodynamically unstable it will not be possible to achieve full resuscitation, therefore attempts should be made to optimally resuscitate before endoscopy to minimise the risk of complications. The risks of endoscopy for people whose condition is unstable should be balanced against the risks of delaying endoscopy.

Clinical judgement should be used to determine whether people who are haemodynamically unstable have achieved their optimal level of resuscitation.