A Sampling of Canadian Practice in Managing Nonvariceal Upper Gastrointestinal Bleeding before Recent Guideline Publication: Is there Room for Improvement?

Abstract

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.

Improving outcomes from acute upper gastrointestinal bleeding: Table 1

“…Despite their derivation over a decade ago, external validation in multiple cohorts and recommendations in evidence-based national and international guidelines,8 data from Canada and the UK show poor adherence to their use. In the Canadian RUGBE study, one out of 15 sites used the Rockall score routinely and explicitly to stratify patients with NVUGIB and none routinely used the GBS 17. Subsequently, in the REASON-2 study only one of 826 patients across 43 participating sites was found to have a Rockall or GBS score documented in the medical records 11.…”

“…These considerations may explain why, in practice, there appears appropriately to be uncertainty among clinicians as to the usefulness of PPIs before endoscopy. In the UK audit, 43% of patients presenting with all-cause UGIB were prescribed a PPI before endoscopy,14 67% in the Italian PNED-1 registry were prescribed a PPI either during the emergency room visit or hospitalisation12 and, in the RUGBE database, 47% of participating sites routinely started a high-dose PPI before endoscopy 17. These uncertainties and variation in practice suggest that further research is needed to evaluate the role of these agents prior to endoscopy.…”

Emergency endoscopy cover: cost and benefits?

“…Only 37% of hospitals had an emergency endoscopy nurses' rota. There is thus a need to increase after-hours availability for the expert delivery of early endoscopy as currently recommended by guidelines, a finding also noted in other countries45 46; perhaps even more disturbing was the realisation that only 41% (666/1640) of first endoscopies performed by trainees were performed under supervision.…”

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“…Various professional society guidelines advocate using the GBS to identify low risk patients [2, 12 -14], and an international consortium on the management of non-variceal UGIB proposed risk stratification of patients as a quality indicator [15]. However, the use of scoring tools for the triage and management of UGIB is uncommon in practice; one national audit demonstrated the complete absence of its systematic use [16].…”