CLINICAL GUIDELINE FOR: Management of low-risk upper GI haemorrhage. Page 1 of 10. Management of low-risk upper GI haemorrhage

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1 CLINICAL GUIDELINE FOR: Page 1 of 10

2 Summary AGE <70 YES NO ADMIT* Glasgow Blatchford Score 2 YES NO ADMIT* Accompanied at home? Telephone? Transport? NO YES ADMIT* Other indication for admission? Frail/other active medical problems? On warfarin/noacs? PMHx varices? YES NO Stop aspirin/nsaids give omeprazole 20mg od NBM from midnight prior to OGD Give patient OGD info sheet and appointment time (10am, next weekday, endoscopy unit, Tower Block, RCHT) Give patient Minor stomach bleeding info sheet (intranet) Complete electronic endoscopy referral on Maxims, stating clearly OP bleed and time patient told to attend Discharge, with the advice to return to hospital immediately if they have further bleeding Page 2 of 10

3 Notes The responsibility for the above management rests with the clinicians assessing the patient at the time of initial attendance at RCHT. *responsibility shifts to admitting medical team(s). Page 3 of 10

4 Aim/Purpose of this Guideline To provide guidelines for clinical staff caring for patients presenting with upper gastrointestinal haemorrhage. 1. The Guidance Responsibility Clinical staff caring for adult patients presenting to Royal Cornwall Hospital with low-risk upper gastrointestinal haemorrhage. Background and evidence base Low-risk upper gastrointestinal haemorrhage may be safely managed in the community without need for hospital admission. 1 A number of scoring systems can be used to assess severity of upper gastrointestinal bleeding. However, a recent UK multi-centre study indicates that the Glasgow Blatchford Score is superior to the Rockall Score at predicting need for intervention, death, 2 or endoscopic therapy. 3 In order to assess the safety of managing patients with low-risk upper gastrointestinal haemorrhage in the community, a 5-year study was conducted of patients presenting to Royal Cornwall Hospital with low-risk upper gastrointestinal haemorrhage who were managed without admission. Low risk was defined as: Glasgow Blatchford Score 2, age < 70 years, no other active medical problems, not taking warfarin, suspected non-variceal bleed. Outcome measures were the need for intervention (blood transfusion, endoscopic therapy or surgery) and death. All patients were offered an out-patient endoscopy appointment to take place the next working day. Of 142 patients who fulfilled the inclusion criteria, none required endoscopic intervention, blood transfusion or surgery, and 28-day mortality was nil. 4 This indicates low-risk patients can be safely managed in the community. References: 1. Stephens et al. Eur J Gastroenterol Hepatol, (12): p Stanley et al. Lancet, (9657): p Stanley et al. Aliment Pharmacol Ther, (4): p McLaughlin et al EuroJGastroHepatol, 2012; 24(3): Definition of low risk upper gastrointestinal haemorrhage Inclusion criteria Exclusion criteria Age <70 Glasgow Blatchford score 2 Unaccompanied at home No telephone at home No transport Other indication for admission Frailty/other active medical problems On warfarin Past history of varices Page 4 of 10

5 GLASGOW BLATCHFORD SCORE Admission risk marker Blood urea (mmol/l) 6.5< < < Hb (g/dl) for men 12<13 10<12 <10 Hb (g/dl) for women 10<12 <10 Systolic BP (mmhg) Patient result Score <90 Other Markers Pulse 100bpm 1 Presentation with melaena 1 Presentation with syncope 2 Hepatic disease 2 Cardiac Failure 2 Total Patient management Patients with a Glasgow Blatchford score 2 aged < 70 years can be considered for management without admission, provided they have no exclusion criteria (see above) Provide patient with: script for omeprazole 20mg od upper GI endoscopy information sheet Patient information sheet minor stomach bleeding (intranet) OGD appointment details (10am nest working day Mon-Friday) Complete electronic endoscopy referral on Maxims Advise patient to discontinue aspirin/nsaids. No insulin or hypoglycaemic agents to be taken on morning of endoscopy. Nil by mouth from midnight immediately prior to OGD. Allow patient home with clear instructions to return immediately if they have any further evidence of GI blood loss or become unwell at home for any other reason. If you are uncertain whether or not the patient is suitable for OP management, please discuss with on call medical registrar, consultant physician or endoscopist. Page 5 of 10

6 2. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared All Dr Dalton Rolling Audit 3-5yearly Gastroenterology Governance Committee Gastroeneterology Governance, Dr James Bebb Required changes to practice will be identified and actioned within 6 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders. 3. Equality and Diversity 3.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 6 of 10

7 Appendix 1. Governance Information Document Title Date Issued/Approved: August 2015 Management of low-risk upper GI haemorrhage Date Valid From: August 2015 Date Valid To: August 2018 Directorate / Department responsible (author/owner): Dr H Dalton, Gastroenterology Contact details: Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Responsibility Evidence base Definition of low risk Patient management Upper GI haemorrhage Glasgow Blatchford Score RCHT PCH CFT KCCG Dr Rob Parry Date revised: August 2015 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Management of Upper Gastrointestinal Haemorrhage Dr A Virr Not Required {Original Copy Signed} Name: Dr James Bebb {Original Copy Signed} Internet & Intranet Intranet Only Page 7 of 10

8 Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Gastroenterology Governance Team can advise Nil No Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) V2.0 Updated guidelines from 2006 Dr H Dalton Dr C Mclaughlin V3.0 Updated guidelines from 2012 Dr H Dalton All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 8 of 10

9 Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Directorate and service area: Is this a new or existing Policy? Medicine/Gastroenterology Existing, updated Name of individual completing Telephone: assessment: Dr H Dalton Policy Aim* Clinical staff caring for patients with upper gastrointestinal Who is the strategy / haemorrhage policy / proposal / service function aimed at? 2. Policy Objectives* Optimize the management of patients with low risk upper 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups gastrointestinal haemorrhage Optimize the management of patients with low risk upper gastrointestinal haemorrhage Audit Our patients with upper gastrointestinal haemorrhage No Page 9 of 10

10 Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Not necessary Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 10 of 10