Acute upper gastrointestinal bleeding:
managing non-variceal bleeding
Clinical audit tool
Implementing NICE guidance
2012
NICE clinical guideline 141
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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)
Acute upper gastrointestinal bleeding: managing non-variceal
bleeding clinical audit tool
This document can be used as a starting point for a local clinical audit project that aims
to improve the management of non-variceal bleeding in people with 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 non-variceal upper gastrointestinal
bleeding. 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 any associated NICE quality standard statements
and exceptions. Exceptions not explicitly referred to in the guideline can be added
locally, for example, patients declining treatment.
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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)
Standards for Acute upper gastrointestinal bleeding clinical audit
Standards
Guidance
reference
Exceptions
Definitions
1.4.1
None
None
1.4.2
None
An example of a
mechanical method is
clips.
1.4.3
None
None
1.4.4
None
None
MANAGING NON-VARICEAL BLEEDING
Endoscopic treatments
For endoscopic treatment, adrenaline monotherapy should not be used.
[See data collection form, question 1]
For endoscopic treatment, one of the following should be used:
 a mechanical method with or without adrenaline
 thermal coagulation with adrenaline
 fibrin or thrombin with adrenaline.
[See data collection form, question 1]
Proton pump inhibitors
Acid suppression drugs (proton pump inhibitors or H2-receptor
antagonists) should not be offered before endoscopy to patients with
suspected non-variceal upper gastrointestinal bleeding.
[See data collection form, question 2]
Proton pump inhibitors should be offered to patients with stigmata of
recent haemorrhage shown at endoscopy.
[See data collection form, question 3]
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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Standards
Guidance
reference
Exceptions
Definitions
1.4.6
None
This should be done with a
view to further endoscopic
treatment or emergency
surgery.
1.4.7
A – Interventional
radiology is not available
The recommendation
states that patients should
be referred urgently for
surgery if interventional
radiology is not promptly
available. The word
‘promptly’ has been left out
of the clinical audit
standard as this isn’t
measurable. The aim of
the recommendation is to
ensure that patients
receive treatment quickly
and are not put at risk by
waiting for interventional
radiology.
Treatment after first or failed endoscopic treatment
A repeat endoscopy should be offered to patients who re-bleed.
[See data collection form, question 4]
Interventional radiology should be offered to unstable patients who
re-bleed after endoscopic treatment.
Patients should be referred urgently for surgery if interventional radiology
is not available.
[See data collection form, question 5]
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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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
MANAGING NON-VARICEAL BLEEDING
Endoscopic treatments
1
For endoscopic treatment, were the following used?
 adrenaline monotherapy
 a mechanical method with adrenaline
 a mechanical method without adrenaline
 thermal coagulation with adrenaline
 fibrin with adrenaline
 thrombin with adrenaline
Proton pump inhibitors
2
3
Was the patient offered acid suppression drugs before
endoscopy when non-variceal upper gastrointestinal
bleeding was suspected?
If the patient with non-variceal upper gastrointestinal
bleeding had stigmata of recent haemorrhage shown at
endoscopy, were they offered a proton pump inhibitor?
Treatment after first or failed endoscopic treatment
4
Did the patient re-bleed after endoscopic treatment?
 If yes, were they offered a repeat endoscopy?
5
If the patient was unstable and re-bled after endoscopic
treatment, was interventional radiology offered?
 If interventional radiology was not available, was the
patient referred urgently for surgery?
*Circle exception code as appropriate.
Exception code
A – Interventional radiology is not available.
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
A
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
Clinical audit tool: Acute upper gastrointestinal bleeding (2012)
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