Audit standards and specific outcomes within the patient variables
| Relevant audit standard | Specific outcomes |
|---|---|
| 1. All patients with rectal bleeding should undergo digital rectal examination and proctoscopy or rigid sigmoidoscopy10 | Frequency of digital rectal examination, proctoscopy, rigid sigmoidoscopy and their findings |
| 2. All patients admitted with LGIB should have a full blood count, coagulation screen and routine biochemistry (consensus opinion) | Frequency of anaemia, thrombocytopenia and deranged clotting Frequency of acute kidney injury Number of patients not tested |
| 3. Continue low-dose aspirin for secondary prevention of vascular events in patients with lower gastrointestinal bleeding in whom haemostasis has been achieved or are considered to have stopped bleeding spontaneously (developed from NICE guidance for UGIB9) | Prevalence of comorbidities Prevalence of antiplatelet use, effect on severity of bleeding, number of patients with aspirin withheld and frequency of cardiovascular complications |
| 4. Stop other non-steroidal anti-inflammatory drugs (including cyclooxygenase-2 inhibitors) during the acute phase in patients presenting with lower gastrointestinal bleeding (developed from NICE guidance for UGIB9) | Prevalence of NSAIDS and numbers withheld |
| 5. Emergency anticoagulation reversal in major haemorrhage* should be with 25–50 U/kg four-factor PCC and 5 mg Vitamin K IV27 6. Reversal for non-major bleeding should be with 1–3 mg IV vitamin K27 | Prevalence of anticoagulants and NOACs, need for reversal agents and the impact on outcomes Methods of warfarin reversal Number of patients that trigger a massive haemorrhage alert |
| 7. Use restrictive red blood cell transfusion thresholds (70 g/L and a haemoglobin concentration target of 70–90 g/L after transfusion) for patients who need red blood cell transfusions and who do not have major haemorrhage or acute coronary syndrome28 | Number of red cell transfusions per patient Threshold and target haemoglobin concentrations used and the frequency of inappropriate or unnecessary blood transfusions Prevalence of pharmacological haemostatic agents such as tranexamic acid |
| 8. Offer platelet transfusion to patients with LGIB who are actively bleeding and have a platelet count of <30×109/L (developed from NICE guidance on transfusion28) 9. Do not routinely give more than a single adult dose of platelets in a transfusion28 | Number of platelet transfusions per patientFrequency of inappropriate or unnecessary platelet transfusions Threshold and target platelet parameters Platelet dose |
| 10. In LGIB offer FFP to patients who have either a fibrinogen level of <1 g/L or a prothrombin time (international normalised ratio) or activated partial thromboplastin time >1.5 times normal (developed from NICE guidance on UGIB9) 11. Use a dose of at least 15 mL/kg when giving FFP transfusions28 | Number of FFP and cryoprecipitate transfusions per patient Threshold and target clotting parameters Frequency of inappropriate or unnecessary use of FFP and cryoprecipitate FFP dose |
| 12. The cause and site clinically significant lower gastrointestinal haemorrhage† should be determined following the early use (within 24 hours) of colonoscopy or flexible sigmoidoscopy or the use of CTA or digital subtraction angiography10 | Frequency of inpatient flexible sigmoidoscopy, colonoscopy and CTA Mean waiting time to investigation frequency and modality of endoscopic haemostasis Number of endoscopies required to reach a diagnosis Frequency of embolisation Rebleeding rate and complications Prevalence of patients with clinically significant bleeding† who had no inpatient investigations |
| 13. Patients with LGIB with clinically significant bleeding† should have an OGD unless the cause has been established using another modality of investigation within 24 hours (developed from NICE guidance on UGIB9) | Number of patients requiring an OGD and number of cases presenting as LGIB subsequently found to have an upper GI source Mean waiting time to OGD |
| 14. When surgery is contemplated, a formal assessment of the risk of death and complications should be undertaken by a clinician and documented in the patient record24 29 15. Localised segmental intestinal resection or subtotal colectomy is recommended for the management of colonic haemorrhage uncontrolled by other techniques10 16. Surgical procedures with a predicted mortality >10% should be conducted under the direct supervision of a consultant surgeon (CCT holder) and consultant anaesthetist unless the consultants are satisfied that the delegated staff have adequate competency, experience, manpower and are adequately free of competing responsibilities29 | Rationale for surgery particularly if first-line treatment Use and findings of surgical risk prediction scores Type of surgery and findings Seniority of operating surgeon and anaesthetist Postoperative complications (pneumonia, perioperative myocardial infarction, venous thromboembolism, wound complications, anastomotic leak) Postoperative intensive care requirements Rebleeding rates |
| Outcomes | In-hospital morbidity (venous thromboembolism, acute coronary syndrome, stroke, pneumonia, acute kidney injury and hospital acquired infection) In-hospital mortality and cause of death 28-day readmissions (further LGIB and other causes) Length of stay Discharge destination (own home, nursing home or rehabilitation facility) |
*Major haemorrhage is defined as the loss of >1 blood volume in 24 hours, loss of 50% of total blood volume in <3 hours, bleeding in excess of 150 mL/min in adults.28 For the purpose of this audit, patients with major haemorrhage were defined as those that triggered a massive haemorrhage alert or equivalent (consensus opinion).
†Clinically significant bleeding: SBP<100, HR>100 and the need for ≥1 unit red cell transfusion (consensus opinion).
CCT, Certificate of Completion of Training; CTA, computed tomography angiography; FFP, fresh frozen plasma; HR, heart rate; LGIB, lower gastrointestinal bleeding; NICE, National Institute for Clinical Excellence; NOAC, novel oral anticoagulant; NSAIDS, non-steroidal anti-inflammatory drugs; OGD, oesophagogastroduodenoscopy; PCC, prothrombin complex concentrate; SBP, systolic blood pressure; UGIB, upper gastrointestinal bleeding.