Simple clinical and laboratory tests could identify patients with stomach bleeds who are low risk and could be safely managed as outpatients. This would clear hospital beds for other patients and cut costs for health services. These are the conclusions of an Article published early Online and in an upcoming edition of The Lancet, written by Dr Adrian Stanley, Glasgow Royal Infirmary, UK, and colleagues.
Stomach bleeds (upper-gastrointestinal haemorrhages) are a frequent cause of admission to hospital, affecting 103-172 per 100,000 adults per year. Most patients do not need endoscopic treatment, surgery, blood transfusion, and do not rebleed or die. Many risk scoring systems incorporate findings from endoscopic examination; but the authors of this study looked at the effectiveness of the Glasgow-Blatchford bleeding score (GBS), which is based on simple clinical and laboratory variables. A score of zero identifies low-risk patients who might be suitable for outpatient management. To obtain a score of zero, patients needed to have a pulse of less than 100 beats per min, systolic blood pressure of more than 110mm Hg, absence of darkened stools, fainting, heart failure or liver disease, haemoglobin of more than 130g/L for men or 120g/L for women, and urea of less than 6.5mmol/L.
The study was done at four UK hospitals, and 676 patients with stomach bleeds were assessed with GBS, and another method called the Rockall score, which assessed patients at admission (pre-endoscopy) and full (post-endoscopy). The researchers found that GBS identified 16% of patients as scoring zero; while for prediction of need for intervention or death, GBS was superior to both Rockall methods. When introduced into clinical practice in two of these hospitals, 123 patients (22%) with stomach bleeds were classified as low-risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with stomach bleeds admitted to hospital also fell from 96% to 71%.
The authors conclude: "Our findings show that simple GBS low-risk criteria can identify a significant proportion of individuals presenting with upper-gastrointestinal haemorrhage who are suitable for outpatient management. Furthermore, use of these criteria in A&E departments leads to a reduction in admissions for this disorder, with no apparent deleterious effects on patients' care... The GBS is based on simple clinical and laboratory variables; therefore, affected individuals can be assessed quickly in A&E departments or at a clinical decision unit."
In an accompanying Comment, Dr Venkataraman Subramanian and Dr Christopher Hawkey, Wolfson Digestive Diseases Centre, University of Nottingham, UK, say: "Stanley and colleagues' study is the first prospective one to assess the use and feasibility of the GBS system in the emergency department. Their calculation of a mean reduction of 1.2 days in bed-days per patient presenting would translate to a direct saving of £13⋅6 million in a population of 60 million, with the assumptions thathospital cost is £227 per day and an annual rate of upper gastrointestinal haemorrhage of 100 per 100 000 people. Further studies will need to compare the cost-effectiveness of the GBS with outpatient endoscopy and strategies that involve early endoscopy and discharge."
Dr Adrian Stanley, Glasgow Royal Infirmary, UK T) +44 (0) 7984 652132 E) Adrian.Stanley@ggc.scot.nhs.uk
Alternative Contact: NHS Greater Glasgow and Clyde Press Office T) +44 (0) 141 201 4429 E) press.office@ggc.scot.nhs.uk
Dr Christopher Hawkey, Wolfson Digestive Diseases Centre, University of Nottingham, UK contact by e-mail E) cj.hawkey@nottingham.ac.uk
Full Article and Comment: http://press.thelancet.com/stomachbleedfinal.pdf
Journal
The Lancet