Prospective evaluation of a clinical guideline recommending hospital length of stay in upper gastrointestinal tract hemorrhage
J. A. Hay, L. Maldonado, S. R. Weingarten and A. G. Ellrodt
HealthCare Partners Medical Group, Pasadena, CA 91105, USA.
CONTEXT: Upper gastrointestinal tract hemorrhage (UGIH) is a common and
potentially life-threatening disorder. Resource utilization can vary
without adverse effect on patient outcome. Clinical practice guidelines are
a potential solution to reduce variation in practice while improving
patient outcomes. OBJECTIVE: To validate prospectively the safety,
acceptability, and impact of a clinical practice guideline defining the
medically appropriate length of stay (LOS) for patients hospitalized with
UGIH. DESIGN: Prospective, controlled time-series study with an
alternate-month design. Outcome surveyors and patients were blinded to
study group allocation. GUIDELINE: A retrospectively validated scoring
system using 4 independent variables: hemodynamics, time from bleeding,
comorbidity, and esophagogastroduodenoscopy (EGD) findings to predict risk
of adverse events. The quantitative risk for the low-risk subset was 0.6%
(95% confidence interval [CI], 0.0%-2.0%) for subsequent complications and
0% (95% CI, 0.0%-0.9%) for life-threatening complications from this
retrospective evaluation. SETTING: A 1000-bed, not-for-profit,
university-affiliated teaching hospital. PATIENTS: Consecutive adult
patients hospitalized for acute UGIH. INTERVENTION: Concurrent feedback of
guideline recommendation (same-day hospital discharge) to physicians caring
for patients at low risk for complication. No risk information was provided
during control months. RESULTS: Seventy percent (209/299) of UGIH patients
achieved low-risk status according to the guideline and were therefore
potentially suitable for early discharge from the hospital. Providing
real-time quantitative risk information (intervention group only) was
associated with an increase in guideline compliance from 30% to 70%
(P<.001) and a decrease in mean (SD) LOS from 4.6 (3.5) days to 2.9
(1.3) days (mean reduction of 1.7 days per patient; P<.001). No
differences in complications, patient health status, or patient
satisfaction were found when measured 1 month after discharge. An
independent variable predicting decreased hospital LOS for low-risk UGIH
patients was early EGD. CONCLUSIONS: Implementation of the clinical
practice guideline safely reduced hospital LOS for selected low-risk
patients with acute UGIH. Further prospective validation in other settings
is warranted.
Implementing guidelines: what works
Livesey and Noon
EDUCATION AND PRACTICE 2007;92:ep129-ep134.
FULL TEXT
Predicting Poor Outcome From Acute Upper Gastrointestinal Hemorrhage
Imperiale et al.
Arch Intern Med 2007;167:1291-1296.
ABSTRACT
| FULL TEXT
Predicting outcome of acute non-variceal upper gastrointestinal haemorrhage without endoscopy using the clinical Rockall Score
Tham et al.
Postgrad. Med. J. 2006;82:757-759.
ABSTRACT
| FULL TEXT
Improving the ICU: Part 2
Garland
Chest 2005;127:2165-2179.
ABSTRACT
| FULL TEXT
Post-endoscopy checklist reduces length of stay for non-variceal upper gastrointestinal bleeding
Romagnuolo et al.
Int J Qual Health Care 2005;17:249-254.
ABSTRACT
| FULL TEXT
Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding
Barkun et al.
ANN INTERN MED 2003;139:843-857.
ABSTRACT
| FULL TEXT
Early Predictors of Severity in Acute Lower Intestinal Tract Bleeding
Strate et al.
Arch Intern Med 2003;163:838-843.
ABSTRACT
| FULL TEXT
Forecasting the Impact of a Clinical Practice Guideline for Perioperative {beta}-Blockers to Reduce Cardiovascular Morbidity and Mortality
Schmidt et al.
Arch Intern Med 2002;162:63-69.
ABSTRACT
| FULL TEXT
Endoscopy for Acute Nonvariceal Upper Gastrointestinal Tract Hemorrhage: Is Sooner Better?: A Systematic Review
Spiegel et al.
Arch Intern Med 2001;161:1393-1404.
ABSTRACT
| FULL TEXT
The Milliman-Robertson Length of Stay Debate
Sparks; et al.
Pediatrics 2000;106:1520-1524.
FULL TEXT
Pediatric Milliman and Robertson Length-of-Stay Criteria: Are They Realistic?
Sills et al.
Pediatrics 2000;105:733-737.
ABSTRACT
| FULL TEXT
Pediatricians' Attitudes, Beliefs, and Practices Regarding Clinical Practice Guidelines: A National Survey
Flores et al.
Pediatrics 2000;105:496-501.
ABSTRACT
| FULL TEXT
Evaluation of Physician Preferences for Guideline Implementation
Stone et al.
American Journal of Medical Quality 1999;14:170-177.
ABSTRACT
The Trials and Tribulations of Clinical Practice Guidelines
Cook and Giacomini
JAMA 1999;281:1950-1951.
FULL TEXT
GUIDELINE REDUCES LENGTH OF STAY FOR UPPER GI BLEEDING
JWatch General 1998;1998:1-1.
FULL TEXT
