A discussion of the British Society of Gastroenterology survey of emergency gastroenterology workload

Abstract

-An electronic survey of 188 acute NHS hospitals was carried out to assess the provision of out-of-hours services for gastrointestinal emergencies in England. The response rate was 167/188 (89%) for the main questionnaire and 157/188 (84%) for a supplementary questionnaire. The survey revealed that the majority of gastroenterologists (135/157, 86%) participate in acute general medicine. A rota for out-of-hours endoscopy was in place in only 82/167 (49%) of hospitals. Trained nurse endoscopy assistance was available in 51/82 (62%) of those hospitals with a formal rota. Two thirds of gastroenterologists were telephoned up to five times each month for advice when not on call; 64% felt their emergency endoscopy service provision was unsatisfactory and 38% thought it was unsafe. This paper concludes that there is serious under provision of services for patients presenting with gastrointestinal emergencies in England.KEY WORDS: British Society of Gastroenterology guidelines, gastrointestinal bleeding, general internal medicine, emergency endoscopy, out-of-hours endoscopy rota IntroductionUpper gastrointestinal (GI) bleeding, acute colitis and decompensated liver disease are emergencies that need urgent gastroenterological attention. In the case of acute GI bleeding, a meta-analysis as early as 1992 demonstrated endoscopic therapy significantly reduced rates of further bleeding, surgery, and mortality. 1 In the case of fulminant colitis and decompensated liver disease, although there are no controlled studies, it would seem reasonable that early specialist input in these life-threatening conditions improves outcome as this has been shown in other areas. 2,3 In 2001, the British Society of Gastroenterology (BSG) made recommendations concerning the essential elements of an emergency endoscopy service. 4 These included consultant delivery, trained endoscopy nurse assistants and appropriate equipment. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 5 report of 2004, analysed the circumstances surrounding the death of patients within 30 days of endoscopy. It highlighted the high rate of death associated with emergency GI endoscopy. Furthermore, delays in endoscopy resulted in suboptimal care and death. In 2005, NCEPOD produced another report examining outcomes in acute medical patients. 6 Among the key recommendations was that of increased direct consultant involvement in the general internal medicine (GIM) take. As the majority of gastroenterologists already provide cover for acute general medicine 7 this may be compromising the provision of specialist out-ofhours GI care. Indeed, prior to 2002 half of hospitals had no emergency on-call rota, and emergency endoscopy when carried out was often done by inexperienced staff in unfamiliar surroundings. 8 In October 2005, a survey of lead clinicians for endoscopy in England was carried out to assess the current level of out-of-hours GI workload and to determine what steps need to be taken to provide a safe and satisfactory emergency GI service ...

Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit

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Services for liver disease in district general hospitals in the UK: a national questionnaire-based survey

“…[9][10][11] The majority of units in our survey offer an acute gastrointestinal bleed service, although a recent report has raised concerns about the organisation of these services with as many as 64% reporting that arrangements were 'unsatisfactory' . 12 Most hospitals use a combination of sclerotherapy and band ligation for varices, and administer terlipressin. The use of antibiotic prophylaxis has been shown to reduce mortality in variceal bleeding.…”

Provision of an out-of-hours emergency endoscopy service: the Leicester experience

“…This difference was not dramatic, as even in hospitals without a formal rota, OOH endoscopies were still being performed on an ‘ad-hoc’ basis, relying on consultant goodwill. Across the UK, there has not been a significant increase in the number of hospitals offering a formal rota, and earlier studies have demonstrated that in 2002 and 2005, 50% and 49% of hospitals, respectively, offered such a service,7 11 which remains deficient in 48% of hospitals 3…”