A call to arms for change: The UK strategy to improve standards of care in acute upper gastrointestinal bleeding

Response

We wish to applaud the Gastroenterololgy Trainee Research and Improvement Network North-West for sharing their experience with acute upper gastrointestinal bleeding (AUGIB) from North West England.¹ Consistent with our own observations and data from previous United Kingdom (UK) audits,^2–4 the authors report issues with attainment both of clinical and service-based quality standards in AUGIB, with 60% of patients receiving delayed endoscopy and poor adherence to Glasgow-Blatchford risk stratification.

Collectively, the UK data demonstrate chronic underperformance in the care of patients with AUGIB and serve as a call to arms for change. These findings draw uncomfortable parallels with the state of colonoscopy 20 years ago,⁵ when unacceptable performance laid bare in the first UK audit catalysed reforms in colonoscopy training, service delivery and unit accreditation under the oversight of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG).⁶ The combination of quality improvement (QI) initiatives led to the strides in colonoscopy quality evidenced in the subsequent UK colonoscopy audit,⁷ culminating in the modern-day legacy of continuous QI in colonoscopy.

In stark contrast, AUGIB has received far less attention, both at individual and service level. In addition to risk stratification and time to endoscopy, adherence to other AUGIB quality measures including the commencement of variceal measures in patients with cirrhosis and antithrombotic resumption following AUGIB remain poor and dependent on frontline clinicians.^3,8 Although local-level educational interventions may provide benefits, these are often temporary. A systems approach to process implementation is therefore required to identify and overcome barriers and to deliver sustained change and QI as seen with colonoscopy.

Behind the scenes, several workstreams are currently being developed in the UK by the British Society of Gastroenterology and JAG to target QI in AUGIB. First, a multi-society DELPHI consensus to implement a care bundle for the first 24-hour management of AUGIB has recently been completed; this will cover aspects including resuscitation, risk assessment, early treatment, early referral for endoscopy and antithrombotic resumption. The care bundle is envisaged to support frontline staff with a pragmatic checklist of interventions to improve adherence to AUGIB quality standards, including time to endoscopy. Second, in collaboration with JAG, standardised and quality-assured courses in AUGIB are being piloted to deliver high-quality theory and simulator-based hands-on teaching. These will supplement plans for future curricula and JAG certification in AUGIB to ensure that endoscopists are equipped both with technical and nontechnical competencies required for managing AUGIB. Third, the National Endoscopy Database project is hosted by JAG and aims to facilitate large-scale quality assurance by automating data extraction from electronic reporting systems across the UK.⁶ Although at its infancy, future quality standards relevant to AUGIB and capturable on electronic reports, e.g. time to endoscopy performance for AUGIB, can be implemented to automate performance monitoring of AUGIB standards at unit level. This can be used to identify and explore factors associated with underperformance and to act as a vehicle for institutional change, thereby facilitating QI.

Finally, with the publication of AUGIB data from three gastroenterology trainee-led regional networks in the UK, it is refreshing to note the enthusiasm and momentum of these networks. To paraphrase the United European Gastroenterology mission statement, trainee networks are well placed to “promote science, research, education and excellent quality of care to reduce health inequalities across Europe”.⁹ Data from trainee-led projects, especially when co-ordinated and upscaled, provide much-needed ammunition for change in areas of suboptimal care. We therefore invite trainees from other regions and across Europe to consider uniting and forging trainee networks. As the current AUGIB data are confined to the UK, we encourage researchers, particularly trainees from non-UK institutions, to report on their time to endoscopy data and consider embarking on collaborative QI endeavours which can ultimately deliver transformations in the care of AUGIB on a multinational scale.

Declaration of conflicting interests

K.S. is supported by a grant from Guts UK and the British Society of Gastroenterology, and is a funded research fellow for JAG.

A.J.M. is the steering committee lead for the UK upper gastrointestinal bleeding care bundle.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.