Rockall T A, Logan R F, Devlin H B, Northfield T C
Surgical Epidemiology and Audit Unit, Royal College of Surgeons of England, London, UK.
Gut. 1997 Nov;41(5):606-11. doi: 10.1136/gut.41.5.606.
To assess changes in practice and outcome in acute upper gastrointestinal haemorrhage following the feedback of data, the reemphasis of national guidelines, and specific recommendations following an initial survey.
A prospective, multicentre, audit cycle. Forty five hospitals from three health regions participated in two phases of the audit cycle.
Phase I: 2332 patients with acute upper gastrointestinal haemorrhage; phase II: 1625 patients with upper gastrointestinal haemorrhage.
Patients were evaluated with respect to management (with reference to the recommendations in the national guidelines), mortality, and length of hospital stay.
Following the distribution of data from the first phase of the National Audit and the formulation of specific recommendations for improving practice, the proportion of hospitals with local guidelines or protocols for the management of upper gastrointestinal haemorrhage rose from 71% (32/45) to 91% (41/45); 12 of the 32 hospitals with guidelines during the first phase revised their guidelines following the initial survey. There was a small but significant increase in the proportion of all patients who underwent endoscopy (from 81% to 86%), the proportion who underwent endoscopy within 24 hours of admission (from 50% to 56%), and the use of central venous pressure monitoring in patients with organ failure requiring blood transfusion or those with profound shock (from 30% to 43%). There was, however, no change in the use of high dependency beds or joint medical/surgical management in high risk cases. There was no significant change in crude or risk standardised mortality (13.4% in the first phase and 14.4% in the second phase).
Although many of the participating hospitals have made efforts to improve practice by producing or updating guidelines or protocols, there has been only a small demonstrable change in some areas of practice during the National Audit. The failure to detect any improvement in mortality may reflect this lack of change of practice, but may also reflect the fact that a large proportion of the deaths in this unselected study are not preventable; only a very large study could hope to demonstrate a significant change out of the context of a clinical trial.
评估在反馈数据、再次强调国家指南以及根据初步调查提出具体建议后，急性上消化道出血的治疗实践和治疗结果的变化。
一项前瞻性、多中心的审计周期研究。来自三个卫生区域的45家医院参与了审计周期的两个阶段。
第一阶段：2332例急性上消化道出血患者；第二阶段：1625例上消化道出血患者。
根据治疗管理（参考国家指南中的建议）、死亡率和住院时间对患者进行评估。
在全国审计第一阶段的数据发布以及为改进治疗实践制定具体建议后，制定了上消化道出血治疗的当地指南或方案的医院比例从71%（32/45）升至91%（41/45）；第一阶段有指南的32家医院中有12家在初步调查后修订了指南。所有接受内镜检查的患者比例有小幅但显著的增加（从81%增至86%），入院24小时内接受内镜检查的患者比例（从50%增至56%），以及在需要输血的器官衰竭患者或严重休克患者中使用中心静脉压监测的比例（从30%增至43%）。然而，高依赖病床的使用或高危病例的联合内科/外科治疗并无变化。粗死亡率或风险标准化死亡率无显著变化（第一阶段为13.4%，第二阶段为14.4%）。
尽管许多参与研究的医院已努力通过制定或更新指南或方案来改进治疗实践，但在全国审计期间，治疗实践的某些方面仅有微小的明显变化。未能发现死亡率有任何改善可能反映了治疗实践缺乏变化，但也可能反映了在这项非选择性研究中，很大一部分死亡是无法预防的这一事实；只有规模非常大的研究才有希望在临床试验背景之外证明有显著变化。
