Retrospective Review of Emergency Department Patients with Non‐variceal Upper Gastrointestinal Hemorrhage for Potential Outpatient Management

Abstract

Abstract.Objective: To determine the number of ED patients with non-variceal upper gastrointestinal hemorrhage (NVUGIH) who could have been managed as outpatients through application of previously developed clinical guidelines. Methods: Descriptive study based on retrospective chart review of patients who presented with acute upper gastrointestinal hemorrhage (UGIH) to the ED of an urban teaching hospital from July 1 to December 31, 1996. Applying the clinical guidelines published by a health maintenance organization (HMO) group (no high-risk endoscopic features/varices/portal hypertensive gastropathy, no debilitation, no orthostatic vital sign change, no severe liver disease, no serious concomitant disease, no anticoagulation or coagulopathy, no fresh, voluminous hematemesis or multiple episodes of melena on the day of presentation, no severe anemia, and adequate home support), patients who could have been managed as outpatients after esophagogastroduodenoscopy (EGD) were identified and analyzed. Results: 145 UGIH patients were seen in the ED, of whom 128 (88%) were admitted and 111 (77%) underwent EGD. 21 (19%) had varices, leaving 90 (81%) with NVUGIH. 18 of these 90 patients (20%, 95% CI = 12% to 28%) fulfilled guidelines for outpatient management and had the following characteristics with p < 0.05: younger age [mean 54.2 Ϯ 5.5 (SEM) vs 63.8 Ϯ 1.9 years], less transfusion (0.9 Ϯ 0.3 vs 3.7 Ϯ 0.4 units), and shorter length of stay (2.1 Ϯ 0.4 vs 5.3 Ϯ 0.7 days). None of the 18 outpatient management patients had any complications. Conclusion: In a non-HMO urban teaching hospital, 18 patients with NVU-GIH met criteria for outpatient management in a six-month period and none developed a complication during a mean in-hospital stay of 2.1 days. Key words: acute upper gastrointestinal hemorrhage; clinical guidelines; outpatient care; bleeding. ACA-DEMIC EMERGENCY MEDICINE 1999; 6:196 -201 I N THE LAST three decades, a number of studies 1 -5 have used clinical and endoscopic features to predict patients' outcomes after upper gastrointestinal hemorrhage (UGIH). It was, however, with the advent of endoscopic hemostasis in the last decade that the management of non-variceal upper gastrointestinal hemorrhage (NVUGIH) changed radically. From numerous studies 5 -11 it was clear that endoscopic features of peptic ulcers enabled clinicians to predict the risk of rebleeding, and appropriate endoscopic intervention helped to reduce this risk. Following this development, at least two studies 12,13 have shown that selected pa- From an emergency medicine point of view, we were particularly interested in the practice guidelines developed by Longstreth and Feitelberg 12 to select patients with UGIH for outpatient care. These guidelines were developed in a health maintenance organization (HMO) setting and we wanted to know whether they would be applicable in a non-HMO urban hospital. The study by Lai et al. 13 addressed only patients with duodenal ulcers and all of them were admitted to the gastroenterology unit before assessment...

Caring for patients in a hospitalist‐run clinical decision unit is associated with decreased length of stay without increasing revisit rates

“…Previous studies have reported the impact of clinical observation or clinical diagnosis units, particularly chest-pain units. [5][6][7][8][9][10][11][12][13][14][15] Studies of hospitalist-run units suggest shorter LOS in the entire hospital, 16 or in the target unit. 17 Although one study suggested a lower 30-day readmission rate, 18 most others did not describe this effect.…”

“…Previous studies have reported the impact of clinical observation or clinical diagnosis units, particularly chest‐pain units . Studies of hospitalist‐run units suggest shorter LOS in the entire hospital, or in the target unit .…”

Proposed risk stratification in upper gastrointestinal haemorrhage: Is hospitalisation essential?

“…Box 1 Conditions to be fulfilled for safe discharge of UGIH patients (based on reviews of references [1][2][3][4][5][6][7] N Age ,60 years N No melaena N No large volume red haematemesis (that is, not greater than a mouthful of blood) N No history of varices or liver damage N Systolic blood pressure .100 mm Hg N No orthostatic change in systolic blood pressure N Haemoglobulin .120 g/l N Absence of significant co-morbidity (see box 2) Box 2 Significant co-morbidity (based on review of references [1][2][3][4][5][6][7] N Cardiovascular: ischaemic pain, congestive cardiac failure; arrhythmias* N Respiratory; acute failure; pneumonia, chronic obstructive pulmonary disease* N Hepatic: cirrhosis, acute hepatitis N Renal: dialysis dependence N Neurological: dementia, delirium, cerebrovascular event , 6 months N Other: malignancy, sepsis *Symptomatic and requiring additional treatment…”

“…The system proposed by Rockall identifies independent predictors of mortality and has been prospectively validated. [2][3][4][5] However, if urgent endoscopy is not widely available these systems are of little practical value. Accurate risk stratification based on clinical and laboratory data alone is not well established.…”