Factors Associated With Emergency Department Discharge, Outcomes and Follow-Up Rates of Stable Patients With Lower Gastrointestinal Bleeding

Martin, Tracey Amanda; Tewani, Sunena; Clarke, Lindsay M.; Aboubakr, Aiya; Palanisamy, Srikanth; Lee, Jihui; Crawford, Carl V.; Wan, David

doi:10.14740/gr1425

Cited by 5 publications

(4 citation statements)

References 17 publications

(28 reference statements)

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“…In a retrospective cohort of 97 patients with stable LGIB, 38% of the cohort was discharged early from the ED with outpatient management; factors associated with early discharge included younger age, lack of antithrombotic medications, higher index hemoglobin and albumin, and lower BUN and creatinine scores. No significant difference was seen in 30-day rebleeding, readmission, or mortality between admitted or discharged patients (142). Finally, in another single-center study of 344 patients with LGIB, patients who were managed with supportive care only had no significant difference in mortality, 30-day readmissions, or inpatient rebleeding compared with patients who underwent diagnostic intervention (143).…”

Section: Timing Of Colonoscopymentioning

confidence: 96%

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

et al. 2022

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Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

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Section: Timing Of Colonoscopymentioning

confidence: 96%

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

et al. 2022

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“…Similar results were also seen in the 2021 Martin et al study. They proposed that patients with an Oakland score of more than 8 with a systolic blood pressure (SBP) > 100 mmHg, HR < 100, and Hb > 13g/dL could be deemed safe to go home [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

External Validation of the Oakland Score for Predicting Safe Discharge in Patients Presenting With Lower Gastrointestinal Bleeding at the William Harvey Hospital in the United Kingdom

Whiteway,

Yim,

Leong

et al. 2024

Cureus

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Introduction Lower gastrointestinal bleeds (LGIB) are defined by having a bleeding point in the gastrointestinal tract beyond the ligament of Treitz. The most common causes include diverticular bleeds, tumours, and colitis. There are no National Institute for Health and Care Excellence (NICE) guidelines regarding safe discharge of patients with LGIB. The aim of this study was to investigate the effectiveness and safety of the Oakland score, as suggested by the British Society of Gastroenterology (BSG) guidelines, in patients presenting with LGIB at William Harvey Hospital. Methods Patients with LGIB who presented to Accident & Emergency or inpatient referral from January to December 2023 were included in this retrospective study. Data was extracted from patients’ Sunrise documentation. The Oakland score for each patient was calculated. Those with a score of ≤8 were deemed safe for discharge; those with a higher score were deemed unsuitable. Patients’ admission, discharges, and adverse outcomes, such as representation, blood transfusion, or further intervention, were investigated. Patients with no adverse outcomes were deemed to have had a safe discharge. The area under the receiver-operating characteristic curve (AUROC) for the Oakland score and adverse outcome (and therefore safe discharge) were calculated. Results A total of 123 patients were included. These led to a total of 144 LGIB presentations to the hospital. Twenty-nine patients had an Oakland score of ≤8; 21 (72.4%) cases were initially discharged with four representations (19.0%) and eight (27.6%) were admitted although none of these suffered from any adverse outcomes. For those who scored ≤8, 25 (86.2%) were therefore deemed to have had a safe discharge. A total of 115 had a score >8; 43 (37.4%) were initially discharged, 72 (62.6%) admitted and 41 (35.7%) experienced at least one adverse outcome including 16 (13.9%) representations, 21 (18.3%) blood transfusions, three (2.6%) surgical interventions and one (0.9%) endoscopic haemostasis. Out of the 115 cases which scored >8, 74 (64.3%) were deemed to have had a safe discharge. The AUROC for safe discharge was 0.84. Conclusion The Oakland score seems to be a safe and reliable tool for identifying LGIB patients who could be safely discharged home without hospital intervention. However, further research is required to assess whether a score of >8 could be used as many patients with a higher score did not experience adverse outcomes.

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“…Higher creatinine levels are associated with higher patient frailty and complexity, although the correlation with creatinine level remains after adjusting for these factors in this study. However, creatinine is an important risk factor for gastrointestinal bleeding and has been associated with increased mortality in several studies [ 14 , 15 , 16 ]. For this reason, the emergency physicians and endoscopists could be more motivated to request and perform early EGDS in these patients.…”

Section: Discussionmentioning

confidence: 99%

Are Short-Stay Units Safe and Effective in the Treatment of Non-Variceal Upper Gastrointestinal Bleeding?

Candelli,

Lumare,

Riccioni

et al. 2023

Medicina

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Introduction: Emergency Department (ED) overcrowding is a health, political, and economic problem of concern worldwide. The causes of overcrowding are an aging population, an increase in chronic diseases, a lack of access to primary care, and a lack of resources in communities. Overcrowding has been associated with an increased risk of mortality. The establishment of a Short Stay Unit (SSU) for conditions that cannot be treated at home but require treatment and hospitalization for up to 72 h may be a solution. SSU can significantly reduce hospital length of stay (LOS) for certain conditions but does not appear to be useful for other diseases. Currently, there are no studies addressing the efficacy of SSU in the treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). Our study aims to evaluate the efficacy of SSU in reducing the need for hospitalization, LOS, hospital readmission, and mortality in patients with NVUGIB compared with admission to the regular ward. Materials and Methods: This was a retrospective, single-center observational study. Medical records of patients presenting with NVUGIB to ED between 1 April 2021, and 30 September 2022, were analyzed. We included patients aged >18 years who presented to ED with acute upper gastrointestinal tract blood loss. The test population was divided into two groups: Patients admitted to a normal inpatient ward (control) and patients treated at SSU (intervention). Clinical and medical history data were collected for both groups. The hospital LOS was the primary outcome. Secondary outcomes were time to endoscopy, number of blood units transfused, readmission to the hospital at 30 days, and in-hospital mortality. Results: The analysis included 120 patients with a mean age of 70 years, 54% of whom were men. Sixty patients were admitted to SSU. Patients admitted to the medical ward had a higher mean age. The Glasgow-Blatchford score, used to assess bleeding risk, mortality, and hospital readmission were similar in the study groups. Multivariate analysis after adjustment for confounders found that the only factor independently associated with shorter LOS was admission to SSU (p < 0.0001). Admission to SSU was also independently and significantly associated with a shorter time to endoscopy (p < 0.001). The only other factor associated with a shorter time to EGDS was creatinine level (p = 0.05), while home treatment with PPI was associated with a longer time to endoscopy. LOS, time to endoscopy, number of patients requiring transfusion, and number of units of blood transfused were significantly lower in patients admitted to SSU than in the control group. Conclusions: The results of the study show that treatment of NVUGIB in SSU can significantly reduce the time required for endoscopy, the hospital LOS, and the number of transfused blood units without increasing mortality and hospital readmission. Treatment of NVUGIB at SSU may therefore help to reduce ED overcrowding but multicenter randomized controlled trials are needed to confirm these data

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Factors Associated With Emergency Department Discharge, Outcomes and Follow-Up Rates of Stable Patients With Lower Gastrointestinal Bleeding

Cited by 5 publications

References 17 publications

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

External Validation of the Oakland Score for Predicting Safe Discharge in Patients Presenting With Lower Gastrointestinal Bleeding at the William Harvey Hospital in the United Kingdom

Are Short-Stay Units Safe and Effective in the Treatment of Non-Variceal Upper Gastrointestinal Bleeding?

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