NICE guidance emphasises the role of endoscopy in treating patients who have upper gastrointestinal bleeding.
- An exclusive summary of new NICE guidance from a member of the guideline development group.
The recently published guideline on the management of acute upper gastrointestinal bleeding emphasises the pivotal role of endoscopy in the care of patients with this problem (National Institute for Health and Clinical Excellence, 2012).
Following resuscitation and risk assessment, patients are endoscoped to:
- Determine the cause of bleeding;
- Treat active bleeding from ulcers;
- Prevent re-bleeding in patients with a “visible vessel” in an ulcer base;
- Manage gastro-oesophageal varices.
Patients who continue to bleed or re-bleed following endoscopic therapy are offered rescue therapies including:
- Intra-arterial embolisation of the bleeding artery;
- Emergency surgery for ulcer bleeding;
- Transjugular intrahepatic portal stent (TIPS) insertion for varices.
The guideline recommends that all patients undergo endoscopy within 24 hours of admission; those who are actively bleeding and haemodynamically unstable should have endoscopy carried out urgently, as soon as possible after resuscitation.
These new recommendations may pose challenges for many hospitals. An audit of UK hospitals undertaken in 2009 found that 45% did not have an out-of-hours (night times and weekend) endoscopy service (Hearnshaw et al, 2010).
The guideline states that units managing more than 330 patients annually should provide daily endoscopy lists including on Saturdays, Sundays and holidays. Such a policy is cost effective as it will not only help to reduce the duration of hospital stay, but also manage the great majority of patients who otherwise would not receive endoscopy within 24 hours. The majority of patients who are actively bleeding could be resuscitated overnight then endoscoped the next morning.
Providing out-of-hours services
The particular challenges for the nursing profession relate to these endoscopic recommendations. Therapeutic endoscopy is demanding and requires not only an expert endoscopist but also expertise from nurses. As the complexity of managing bleeding ulcers and varices is increasing - including the use of injection catheters, equipment to cauterise vessels, and clips and bands for ulcers and varices - it has become clear that expert nurses are needed to offer an appropriate service.
The UK audit showed only a minority of hospitals have out-of-hours nursing assistance, even in institutions in which there are 24-hour endoscopy rotas (Hearnshaw et al, 2010).
Given that mortality remains unacceptably high for about 10% of patients admitted with bleeding, and approximately 25% of those who bleed as established inpatients (Hearnshaw et al, 2010), there will undoubtedly be pressures to improve the management of GI bleeding. Only by stopping bleeding as soon as possible is it likely that this depressing statistic will improve. The need to have endoscopy nurses on call for out-of-hours and weekend management of bleeding, or at least for daily endoscopy, will clearly put pressure on nursing rotas.
In addition to recommendations regarding out-of-hours cover, there are other implications for nursing staff. Perhaps the most relevant of these is the emphasis on good communication with patients and their relatives. The guideline emphasises that information given to patients and families, by both medical and nursing staff, should be consistent and documented in case records. It is clearly important that the same message is given to these patients who are often critically ill and their families, who are usually very anxious.
The guideline is available for download here.
Kelvin Palmer is consultant gastroenterologist, GI unit, Western General Hospital, Edinburgh, and chair of the guideline development group.
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Hearnshaw SA et al (2010) Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit. Gut; 59: 8, 1022-1029.
National Institute for Health and Clinical Excellence (2012) Gastrointestinal Bleeding: the Management of Acute Upper Gastrointestinal Bleeding. London: NICE.