The principal diagnostic test for people with acute upper GI bleeding is endoscopy. For these patients reduced endoscopy waiting times (diagnostic and therapeutic) lead to more rapid diagnosis and reductions in mortality, requirements for transfusions, risk of re-bleeding and length of hospital stay. With such benefits to patients and the NHS, the NICE clinical guideline 'Acute upper GI bleeding' (CG141 June 2012) recommends offering endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding as key priorities for implementation (see guideline for recommendations in full). The Royal Bolton Hospital NHS foundation trust re-engineered their endoscopy service and the care pathways for patients with acute upper GI bleed in order to enhance the quality of care for patients and implement these recommendations.
Aims and objectives
Additionally, it is anticipated that increasing availability of endoscopy services will also enhance the quality of care for all other patients requiring endoscopy, and reduce the waiting times for access to endoscopy.
The new working model for the endoscopy service:
- 7 day working endoscopy unit: Monday to Sunday 08:00 - 18:00
- Outside of these hours an on-call endoscopy service is available via theatres for urgent endoscopy cases (which includes patients with acute upper GI bleed who are haemodynamically unstable). This is covered between Upper GI surgeons and the gastrointestinal physicians.
- 2-3 emergency slots are kept free on the daily endoscopy lists for patient with acute upper GI bleed
- 3 endoscopy nurse specialists and 4 senior recovery nurses contact the medical and surgical wards a number of times per day in order to rapidly identify newly admitted patients with acute upper GI bleeding (and other problems) who require endoscopy. The nurses then add the patients to either the morning or afternoon lists.
Please note in the context of this report 'endoscopy' refers to diagnostic and where necessary therapeutic endoscopy. - Deliver urgent endoscopy to patients with acute upper GI bleeding who are haemodynamically unstable.
- Provide endoscopy within 24 hours to all other patients with acute upper GI bleeding.
- Reduce the length of stay of patients admitted with acute upper GI bleeding.
- Reduce the complication rate of patients admitted with acute upper GI bleeding.
- Increase the productivity of the endoscopy unit (for all purposes) and bring benefit to patients other than those with acute upper GI bleeding.
Reasons for implementing your project
The working model of the endoscopy unit prior to the implementation of the new model was 08:00 - 18:00 Monday to Friday.
It was anticipated that the benefits and savings of implementing the new working model to reduce the waiting times for urgent endoscopy would be seen in the following areas:
- Reduced length of stay of patients admitted with acute upper GI bleed
- Reduced complications (for example death, requirement for blood transfusions, re-bleeds) in patients admitted with acute upper GI bleed
- Enhanced access to endoscopy for patients other than those with acute upper GI bleed. As well as being beneficial to patients this will also increase the activity of the hospital trust. One benefit The Royal Bolton anticipated was in facilitating their compliance with guidance relating to the colorectal screening programme.
- By implementing the seven day working model it was anticipated that the requirement for overnight emergency endoscopy would be reduced.
How did you implement the project
- Inpatient acute gastrointestinal bleeds. The Royal Bolton identified that this group of patients were a high risk group and the new working model would provide the opportunity for quick and appropriate management which would lead to reduced complications.
- Lower GI bleeds.
- Cancer screening service.
The key cost of implementing this service to reduce delay to endoscopy was additional staff hours. It was anticipated that the expected benefits and savings identified in the context section would offset the cost of increasing the staff hours. A business case was put together to estimate the likely costs and savings of implementing this change. The case identified potential savings and increase in the quality of patient care which supported the implementation of the change.
Key learning points
The key to the establishment of the out of hours service was the provision of a dedicated service at weekends.
Following the success of this project the Royal Bolton are in the process of ensuring that all patients with acute upper GI bleeding are admitted to either a gastro or surgical ward (not the medical wards). The Royal Bolton is looking to enhance this model further by developing a dedicated 'bleeding unit' next to the endoscopy unit.
The Royal Bolton are also in the process of implementing a project which will facilitate more rapid access to endoscopy for patients presenting with acute upper GI bleed at smaller units in their region (who may not have out of hours endoscopy provision). In these smaller units they are rarely presented with cases of acute upper GI bleed and therefore it may not be possible for them to provide additional endoscopy lists in order to meet the NICE recommendations. The Royal Bolton are looking at developing a network where smaller hospitals transfer relevant patients in to the Royal Bolton for endoscopy within the timeframes set by NICE.