Acute upper gastrointestinal bleeding:
initial management
Clinical audit tool
Implementing NICE guidance
2012
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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NICE clinical guideline 141
This clinical audit tool accompanies the clinical guideline: ‘Acute upper gastrointestinal
bleeding: management’. http://guidance.nice.org.uk/CG141.
Issue date: 2012
This document is a support tool for clinical audit based on the NICE guidance. It is not
NICE guidance.
Acknowledgements
NICE would like to thank the following people who have contributed to the development
of this clinical audit tool and have agreed to be acknowledged:
Phil Willan, HQIP Patient Network & RCoP Patient Network
Natasha Pradhan, Independent Emergency Nurse Specialist
NICE has adapted the action plan template produced by the Healthcare Quality
Improvement Partnership (HQIP) in their template clinical audit report.
National Institute for Health and Clinical Excellence
Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk
© National Institute for Health and Clinical Excellence, 2012. All rights reserved. This material
may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for
commercial organisations, or for commercial purposes, is allowed without the express written
permission of NICE.
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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Acute upper gastrointestinal bleeding: initial management clinical
audit tool
This document can be used as a starting point for a local clinical audit project that aims
to improve the initial management of acute upper gastrointestinal bleeding. It contains:
 clinical audit standards
 a data collection form
 an action plan template.
There is also an electronic audit tool available, which can be used with this document
or on its own to collect and analyse the data.
The audit standards and data collection form can be adapted to focus on a smaller part
of the tool or expanded to include other local priorities.
The audit could be carried out in the following services: gastrointestinal services.
The audit sample should include people with suspected or confirmed acute upper
gastrointestinal bleeding. Most of the standards assume the patient’s upper
gastrointestinal bleeding is confirmed and those that are relevant specifically to people
with suspected upper gastrointestinal bleeding make explicit reference to this group.
Advice on how to decide on sample size is available on HQIP’s website.
The audit standards are based on the NICE clinical guideline for acute upper
gastrointestinal bleeding. In developing this tool consideration has been given to the
clinical issues covered by the guideline and the potential challenges of data collection.
There may be other recommendations within the guideline suitable for the development
of audit standards or an audit project.
A baseline assessment tool is available. This can help to compare practice with the
guideline’s recommendations and prioritise implementation activity, including clinical
audit.
The audit standards in this document include a reference to the guideline
recommendation numbers and exceptions. Exceptions not explicitly referred to in
the guideline can be added locally, for example, patients declining treatment.
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NICE recommends compliance of 100%. If this is not achievable an interim local target
could be set, although 100% should remain the ultimate aim.
A data collection form should be completed for each patient. There is a section for
demographic information that can be completed if this information is essential to the
project. Patient identifiable information should never be recorded.
Following the audit the action plan template can be used to develop and implement
an action plan to take forward any recommendations made.
Re-audit is a key part of the clinical audit cycle, required to demonstrate that
improvement has been achieved and sustained. Once a re-audit has been completed,
the shared learning database can be used to share the experience of putting NICE
guidance into practice.
For further information about clinical audit refer to a local clinical audit professional in
your own organisation or the HQIP website.
To ask a question about this clinical audit tool, or to provide feedback to help inform
the development of future tools, please email [email protected]
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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Standards for Acute upper gastrointestinal bleeding clinical audit
Standards
Guidance
reference
Exceptions
Definitions
1.1.1
None
None
1.2.3
None
None
1.2.4
None
None
INITIAL MANAGEMENT
Risk assessment
The following risk assessment scores should be used for all patients:
 the Blatchford score at first assessment
 the full Rockall score after endoscopy.
[See data collection form, question 1]
Blood products
Platelet transfusion should not be offered to patients who are not actively
bleeding and who are haemodynamically stable.
[See data collection form, questions 2 and 3]
Patients with massive and/or ongoing bleeding
Platelet transfusion should be offered to patients who are actively
bleeding and have a platelet count of less than 50 x 109/litre.
[See data collection form, questions 4 to 6]
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Standards
Guidance
reference
Exceptions
Definitions
Fresh frozen plasma for patients with acute upper gastrointestinal bleeding not related to liver disease
Fresh frozen plasma should be offered to patients with either:
1.2.5
None
None
1.2.6
None
None
1.3.1
None
None
1.3.2
None
None
 a fibrinogen level of less than 1 g/litre or
 a prothrombin time (international normalised ratio) or activated
partial thromboplastin time greater than 1.5 times normal.
[See data collection form, questions 7 and 8]
Patients who are taking warfarin
Prothrombin complex concentrate should be offered to patients who are
taking warfarin and actively bleeding.
[See data collection form, questions 9 and 10]
Timing of endoscopy
Unstable patients with severe acute upper gastrointestinal bleeding
should receive endoscopy immediately after resuscitation.
[See data collection form, question 11]
All patients other than unstable patients with severe acute upper
gastrointestinal bleeding should receive endoscopy within 24 hours of
admission.
[See data collection form, question 12]
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Data collection form for Acute upper gastrointestinal bleeding
clinical audit
Audit ID:
Sex:
Age:
The audit ID should be an anonymous code. Patient identifiable information should never be recorded.
White
British
Irish
Any other white
background
No.
Mixed
White and black
Caribbean
White and black
African
White and Asian
Asian or Asian British
Indian
Black or black British
Caribbean
Other
Chinese
Pakistani
African
Bangladeshi
Any other black
background
Any other
ethnic group
Not stated
Any other mixed
background
Any other Asian
background
Question
Yes
No
Exception/
NA/Notes
INITIAL MANAGEMENT
Risk assessment
1
Were either of the following used?
 the Blatchford score at first assessment
 the full Rockall score after endoscopy
Blood products
2
3
Was the patient haemodynamically stable without active
bleeding?
Were they offered platelet transfusion?
Patients with massive and/or ongoing bleeding
4
5
Was the patient actively bleeding?
Did they have a platelet count of less than 50 x 109/litre?
6
Were they offered platelet transfusion?
Fresh frozen plasma for patients with acute upper gastrointestinal bleeding not related to liver
disease
7
8
Did the patient have:
 fibrinogen level of less than 1 g/litre?
 prothrombin time (international normalised ratio) greater
than 1.5 times normal?
 activated partial thromboplastin time greater than 1.5
times normal?
Were they offered fresh frozen plasma?
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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Patients who are taking warfarin
9
Is the patient:
 taking warfarin?
 actively bleeding?
10
Were they offered prothrombin complex concentrate?
Timing of endoscopy
11
12
If the patient is unstable with severe bleeding, did they
receive endoscopy immediately after resuscitation?
If the patient is not unstable with severe bleeding, did they
receive endoscopy within 24 hours of admission?
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Action plan for Acute upper gastrointestinal bleeding clinical audit
KEY (Change status)
1 Recommendation agreed but not yet actioned
2 Action in progress
3 Recommendation fully implemented
4 Recommendation never actioned (please state reasons)
5 Other (please provide supporting information)
Action plan
lead
Name:
Title:
Contact:
The ‘Actions required’ should specifically state what needs to be done to achieve the recommendation. All updates to the action plan should be
included in the ‘Comments’ section.
Recommendation
Actions required
(specify ‘None’, if
none required)
Action by
date
Person
responsible
Comments/action status
(Provide examples of action in progress,
changes in practices, problems
encountered in facilitating change, reasons
why recommendation has not been
actioned etc.)
Change
stage
(see Key)
When making improvements to practice, organisations may like to use the tools developed by NICE to help implement the clinical guideline on
Acute upper gastrointestinal bleeding. http://guidance.nice.org.uk/CG141
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