Upper GI Bleeding: Practice Guidelines Reduce LOS
ABSTRACT & COMMENTARY
Synopsis: A clinical practice guideline defining the medically appropriate length-of-stay (LOS) for patients hospitalized with upper gastrointestinal hemorrhage reduced average LOS by 1.7 days without increasing complications or affecting patient satisfaction.
Source: Hay JA, et al. JAMA 1997;278:2151-2156.
Hay and associates used observational studies from the literature and their own database from Cedars-Sinai Medical Center in Los Angeles to create and retrospectively validate a risk-stratification model incorporating four variables to predict the likelihood of further bleeding in patients admitted with upper gastrointestinal hemorrhage (UGIH). The four variables were findings at endoscopy, elapsed time since the onset of bleeding, hemodynamic status, and the number of comorbidities present. The investigators then used a one-month on, one-month off time-series designed to examine the effects of implementation of the model on ICU, hospital LOS, and patient outcomes.
During the "on" or implementation months, use-management coordinators screened patients, provided practitioners with concurrent prognostic information on patients at low risk for further hemorrhage, and recommended early discharge through structured messages on the patients’ charts and by telephone calls. During the "off" or control months, no risk information or discharge recommendations were provided to the primary physician.
Of the 299 patients in the study, 93 of whom were admitted to the ICU, 209 achieved low-risk status according to the guideline and were appropriate for early hospital discharge. For these patients, implementation of the intervention increased guideline compliance from 30% to 70% (P < 0.001) and decreased mean hospital LOS by 1.7 days per patient (P < 0.001). Duration of stay in the ICU was also significantly shorter during the "on" months (mean ICU LOS 1.3 vs 1.8 days; P < 0.001). There were no detectable differences in complications, patient health status, or patient satisfaction between the intervention and control patient groups when assessed one month after discharge. In addition, this study found that early esophagogastroduodenoscopy was a significant independent variable predicting decreased LOS for low-risk patients with UGIH.
COMMENT BY DAVID J. PIERSON, MD
This study shows that hospital and ICU LOS can be safely shortened in patients with UGIH who are determined to be at low risk for recurrent bleeding or other adverse events through the use of a clinical practice guideline. These benefits were achieved without evidence of harm to the patients or a detrimental effect on patient satisfaction. As pointed out in the accompanying editorial (Peterson WL, Cook DJ. JAMA 1997;278:2186-2187), practice guidelines such as the one evaluated in this study have the greatest potential to improve care if they are evidence-based, available at the point of care, presented concisely and clearly to clinicians, and accompanied by appropriate documentation allowing affected clinicians to critically appraise how they were developed. This study is an excellent example of this type of health services research as applied to a common problem managed in the ICU.
Implementation of a practice guideline for patients hospitalized with acute upper GI bleeding led to:
a. earlier discharge but increased readmissions for rebleeding.
b. earlier discharge but decreased patient satisfaction.
c. earlier discharge without increased complications or changes in patient satisfaction.
d. no change in length of stay but decreased complications.
e. none of the above.
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