Clinical outcomes of inter-hospital transfers for upper GI bleeding and the utility of the Glasgow blatchford score

Introduction

The British Society of Gastroenterology guidelines on the management of suspected acute upper gastrointestinal bleeding (AUGIB) recommend that endoscopy (OGD) is performed within 24 hours of presentation. However, certain hospital sites in the UK have no provision for therapeutic endoscopy and the optimal AUGIB scoring system for inter-hospital transfers has not been determined. In our trust, patients at a district general hospital (DGH) are transferred to tertiary care (Royal Infirmary of Edinburgh, RIE) if their Glasgow-Blatchford Score (GBS) is ≥2. We investigated the clinical utility of GBS as a screening tool for inter-hospital transfers and investigated time to endoscopy for all AUGIB transfers.

Methods

Data were collected using NHS Lothian Trakcare. All transfers with a suspected AUGIB were included from January to June 2022. Case note review was performed to record demographics, timings for inter-hospital transfer and endoscopy, and endoscopic findings.

Results

26 patients were transferred to RIE with AUGIB. 62% were male; the average age was 65 (range 29–91). 14 patients (54%) were transferred out of hours. 18 patients had a departmental OGD (69%), with 6 (23%) undergoing OGD in critical care or theatre. 3 (12%) patients had varices. Only 33% of patients undergoing departmental OGD required therapy (4 ulcers, 1 varix, 1 gastric antral vascular ectasia) compared to 50% of patients undergoing non-departmental OGD (1 ulcer, 2 varices). No patient required interventional radiology or surgery to control the bleeding. The range of GBS scores is shown in figure 1. Time from presentation to OGD averaged 31 hours for departmental OGD vs 15 hours for non-departmental OGD (IQR 19–48 vs 14–24, p<0.01); and 14 hours for variceal bleeds vs 27 hours for non-variceal bleeds (IQR 14–20 vs 19–49, p=0.02). The median time to transfer from presentation at the DGH to RIE was 6 hours (IQR 4–7). Time from arrival at RIE to departmental scope averaged 27 hours vs 9 hours for non-departmental scope (IQR 14–42 vs 5–15, p=0.86). Figure 1. Glasgow-Blatchford Scores

Conclusions

In conclusion, only 1/3rd of patients who underwent departmental OGD required endoscopic therapy, and a patient scoped in theatre required therapy with a GBS of 2. This data suggests that GBS, or the current threshold of ≥2, may not be the ideal inter-hospital transfer scoring system for AUGIB. Although there were delays to endoscopy, most patients did not require therapy. Further work is planned to examine the optimal scoring system and factors that would help optimise inter-hospital transfers for AUGIB therapy, especially amongst those with non-variceal bleeding.