Tool predicts safe ED discharge for those with lower GI bleeding

Last Updated: 2017-07-17

By Marilynn Larkin

NEW YORK (Reuters Health) - Researchers have developed a tool that can help assess when patients with acute lower gastrointestinal bleeding can safely be managed as outpatients.

"Lower gastrointestinal bleeding is a very common reason for hospitalization and is associated with significant costs and resource utilization," Dr. Neil Sengupta of the University of Chicago Medical Center told Reuters Health.

"The majority of patients with lower gastrointestinal bleeding do well and performance of in-hospital procedures such as colonoscopies has not been shown to alter important clinical outcomes," he said by email.

"Thus," he observed, "identification of patients within the emergency room who are at low risk for complications represents a valuable opportunity to efficiently manage patients in the outpatient setting, thereby significantly limiting costs to the healthcare system."

Dr. Vipul Jairath of the University of Western Ontario in London and colleagues developed a tool to identify such patients by analyzing 2015 data from the National Comparative Audit of Lower Gastrointestinal Bleeding, which includes input from 143 hospitals in the UK.

They identified predictors of safe discharge and developed a tool based on 2,336 prospectively identified patients who were admitted to the emergency department with lower gastrointestinal bleeding.

Safe discharge was defined as no rebleeding, blood transfusion or therapeutic intervention after 24 hours of stability; and the absence of readmission or death within 28 days.

In the development cohort, 1,599 patients (68%) were safely discharged and 737 (32%) were not safely discharged.

The researchers validated the tool in 288 patients (184 safely discharged) from two UK hospitals that had not contributed data to develop the tool.

Age, gender, previous admission for lower gastrointestinal bleeding, rectal examination findings, heart rate, systolic blood pressure, and hemoglobin concentration strongly discriminated a safe discharge in both the development and validation cohorts, according to the authors. The score component values were published online June 23 in The Lancet Gastroenterology and Hepatology.

To increase the uptake and usability of the model, they created a simplified scoring system, assigning values to risk factor categories so that their sum predicted probabilities of safe discharge. A score of 8 or less predicted a 95% probability of safe discharge.

The new tool, called the Oakland Score, was more effective in its ability to discriminate patients who were safely discharged than were Blatchford, Rockall, and AIMS65 scores, which have been designed for upper gastrointestinal bleeding but could have some value in lower gastrointestinal bleeding. The Oakland score was also more effective than the BLEED score, which has been validated for upper or lower gastrointestinal bleeding, and the Strate and NOBLADS scores, which have been developed for lower gastrointestinal bleeding but not externally validated.

Dr. Sengupta, who coauthored an editorial accompanying the study, said, "This clinical prediction tool finally provides frontline clinicians real-world data to risk stratify patients with lower gastrointestinal bleeding, thereby potentially saving healthcare systems millions of dollars annually."

"This study provides justification for a multicenter randomized trial formally utilizing this tool in the emergency room setting," he added. "Prior to widespread implementation, we need to ensure that adverse outcomes and complication rates are truly minimal in those patients who are deemed low risk by the clinical prediction tool."

The authors did not respond to requests for comment.

SOURCE: http://bit.ly/2tyBadq and http://bit.ly/2typaZh

Lancet Gastroenterol Hepatol 2017.