Do upper GI bleed guidelines reach patient care: effect of a quality improvement initiative

Abstract

Background: Adherence is variable in clinical practice to consensus guidelines on the management of upper gastrointestinal bleeding. We aimed to assess the effect of a quality improvement program (QIP) on guideline adherence.

Methods: A QIP was undertaken over a two-month period. Data were collected retrospectively, for the one-year pre QIP and prospectively for one-year post QIP. The QIP goals were adherence to criteria for the timing of oesophagogastroduodenoscopy (OGD), achievement of dual endotherapy and blood transfusion triggers.

Results: Fifty-one patients were pre QIP and 58 post QIP. The two groups’ baseline data were comparable. Over 80% had their OGD within 24 hours (pre  QIP 82.3%, post QIP 81.0%). The overall and high-risk groups (variceal and MBS > 10) had an insignificantly longer time to OGD (mean 19.2 and 17.8 hours  respectively) in the post QIP cohort (mean 14.2 and 15.2 hours).The practice of dual endotherapy improved post QIP (p = 0.02) for non-variceal  bleeding. The Hb g/dL (mean + SD) in stable patients who were transfused was significantly different pre QIP (6.3 + 2) and post QIP (5.7 + 1.69) (p = 0.04). Twelve patients (23.5%) were transfused for Hb above 7 g/dl pre QIP and six (10.3%) post QIP (p = 0.047). Thirty-day mortality rate was 9.8% (pre QIP) and  10.3% (post QIP). Univariate analysis showed that Grade III shock was the only significant factor in determining 30-day mortality.

Conclusion: This QIP had no effect on time to OGD adherence which compares favorably to similar audits. Adherence to transfusion triggers and the  ability to deliver dual endotherapy routinely were positive QIP outcomes.