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Jeffrey A. Hay, MD; Lawrence Maldonado, MD; Scott R. Weingarten, MD, MPH; A. Gray Ellrodt, MD

JAMA. 1997;278(24):2151-2156.

Abstract
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.

Patioents.
—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.

Author Affiliations
From the HealthCare Partners Medical Group, Pasadena, Calif (Dr Hay), and Cedars-Sinai Medical Center, Departments of Medicine (Drs Maldonado, Weingarten, and Ellrodt) and Health Services Research (Drs Weingarten and Ellrodt), UCLA School of Medicine, Los Angeles, Calif.

Footnotes
In addition to his position at Cedars-Sinai Health System, Dr Weingarten works for a wholly owned subsidiary of Cedars-Sinai Health System that markets clinical decision support software and consulting services.

Reprints: Jeffrey A. Hay, MD, HealthCare Partners Medical Group, 55 E California Blvd, Pasadena, CA 91105.

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