Over half of patients who need emergency investigation of sudden bleeding from their gut are still facing potentially "serious" delays, finds an audit of endoscopy services across the UK.
Endoscopy involves passing a camera on the end of a flexible tube down the gullet into the stomach. It is a recommended procedure for this type of bleed, known as acute upper gastrointestinal bleeding or AUGIB.
AUGIB is a common medical emergency, usually caused by bleeding from ulcers in the stomach or from veins (variceal bleeds) in the gullet (oesophagus).
It is thought to affect between 50 to150 people in every 100,000 of the population, and results in an annual death toll of 4000 in the UK. Timely endoscopy can therefore save lives, say the authors.
The research team monitored 208 hospitals out of 257 across the UK that admit adult patients with AUGIB for a period of two months in the summer of 2007.
During this period, the records of 6750 patients were checked, three quarters of whom underwent endoscopy while in hospital.
Of these, half took place within the recommended 24 hours of admission, with more than 8 out of 10 investigations carried out during normal working hours. But about 17% took place outside normal working hours (out of hours) including 3% between midnight and 0800 hours.
But of those patients deemed to be at high risk of dying, as assessed by a validated (Rockall) risk score of 5 or more, only just over half (55%) were endoscoped within 24 hours. And 14% of them waited 72 or more hours for the procedure.
Endoscopy revealed that almost a third of patients (28%) were bleeding from conditions that carry a high risk of further bleeding. Three out of four of these patients were endoscoped again. Further bleeding occurred in 13%, over half of whom (7.4%) died.
About half of hospitals (52%) had an organised out of hours endoscopy service, often provided by a specialist, the audit showed. But this figure has scarcely risen since 2005, say the authors.
Hospitals without this type of service depend on the availability and goodwill of specialists who are not on call. One in five initial endoscopies were performed out of hours in hospitals with this service compared with only 13% among those without.
Standard endoscopic therapy, which curbs the risk of re-bleeds and surgery, was also underused, the audit showed. Just over three out of four patients with visible or bleeding blood vessels were given appropriate treatment at endoscopy.
The overall findings are similar to those of a previous audit in 1993, which involved only four regions in England, say the authors.
"This figure [for endoscopy] has not increased since the 1993 audit, even though it is prominently recommended in the [British Society for Gastroenterology] guidelines and those of other organisations," they comment.
"Use of endoscopic therapy for high risk lesions has also increased little since 1993," they add, pointing to the doubling in prevalence of bleeding from gullet veins - an indication of the increasing numbers of patients with advanced alcoholic liver disease - between 1993 and 2007.
They note that the numbers of patients needing surgery and dying as a result of AUGIB have fallen, but nevertheless conclude: "This audit has identified serious deficiencies in the use of endoscopy for AUGIB in the UK."
Source: BMJ-British Medical Journal