A sampling of Canadian practice in managing nonvariceal upper gastrointestinal bleeding before recent guideline publication: is there room for improvement?

BACKGROUND: There are few recent published consensus guidelines regarding nonvariceal upper gastrointestinal bleeding. In 2003, the Canadian Association of Gastroenterology sponsored a set of 20 recommendations. AIM: To compare current Canadian clinical practice patterns with these most recent guidelines. METHODS: Data obtained from the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), complemented by a questionnaire sent out to the 18 participating RUGBE sites, were used to compare present practice with all 20 guidelines. RESULTS: Only three RUGBE sites had an explicit written protocol for nonvariceal upper gastrointestinal bleeding, and only 40% of the sites had support staff available after hours. The Blatchford prognostic scale was not used routinely, and only one site used the Rockall score for risk stratification. Most patients classified as low-risk according to the literature had endoscopy within 24 h and a median length of stay of two days compared with high-risk patients who underwent endoscopy approximately 4 h earlier, had a median length of stay of 4.3 days and displayed a higher mortality. Nineteen per cent of all patients had a routine second-look endoscopy. Proton pump inhibitors were frequently used in the acute setting. Thirteen per cent of all patients rebled and only 34% of these received a second endoscopy. One-half of all patients were tested for Helicobacter pylori while in hospital, mostly by histology, and one-third of those who tested positive received H pylori eradication during their hospitalization. CONCLUSION: Compared with recommendations put forward in the new guidelines, clinical practice before guideline publication was variable. The future level of guideline adherence and patient outcome data should be quantified and monitored as the guidelines are disseminated.

The importance of process issues as predictors of time to endoscopy in patients with acute upper-GI bleeding using the RUGBE data.

BACKGROUND: Early endoscopy has been shown to improve outcomes and optimize cost-effectiveness in nonvariceal upper-GI bleeding (NVUGIB). However, there is little information regarding clinical and process determinants that affect the time from onset of bleeding to performance of the endoscopy. OBJECTIVE: The aim of this study was to identify factors that predict time to endoscopy in patients with new onset NVUGIB. DESIGN: Linear regression models were constructed with time between triage (outpatients) or onset of bleeding (inpatients) and the performance of endoscopy. SETTING: The RUGBE is a nationwide, multicenter database collected for the purpose of obtaining descriptive data on patients with NVUGIB. PATIENTS: The study population consisted of 1500 patients (89.6%) who underwent gastroscopy within 48 hours. RESULTS: Median time to endoscopy was 12 hours (95% CI 11.0, 13.0). Endoscopy after working hours (regression coefficient [beta] -3.52; 95% CI -5.47, -1.58), availability of an endoscopy nurse on-call for the procedure (beta -2.48; 95% CI -3.83, -1.14), and admission to a hospital unit were associated with a shorter interval to endoscopy. In contrast, the presence of chest pain (beta 3.65; 95% CI 1.64, 5.67) or dyspnea (beta 2.79; 95% CI 1.10, 4.48), absence of gross blood on rectal examination (beta 2.20; 95% CI 0.69, 3.71), and inpatient status at onset of bleeding (beta 14.6; 95% CI 8.70, 20.4) were independent predictors of a delayed endoscopy. Subgroup analysis showed that actual time intervals as well as independent predictors of time until endoscopy differed between inpatients and outpatients. LIMITATIONS: Retrospective analysis. CONCLUSIONS: The timing of endoscopy in patients with NVUGIB is dependent on both clinical and process parameters, which differ between inpatient and outpatient settings. They bear implications with regards to shaping practice and deciding on resource allocation in order to facilitate an early endoscopy, which is currently recommended for improved patient outcomes.