4701 A randomized trial comparing a clinical pathway versus usual care for patients with non-low risk upper gastrointestinal hemorrhage.

Abstract

Background: Clinical pathways for the treatment of upper gastrointestinal hemorrhage (UGIH) have been proposed to standardize care and reduce hospital length of stay (LOS). Previous retrospective studies have shown UGIH treatment pathways to safely decrease LOS in low-risk patients to 2-3 days. Prior to this study, median LOS at our hospital for non-low risk (NLR) UGIH patients was 5 days. Aims: 1) To assess if a clinical pathway decreases LOS in patients with NLR UGIH. 2) To compare rates of adverse outcomes between pathway and usual care in NLR patients with UGIH. Methods: 54 patients with signs of UGIH were assessed in the emergency room and designated as NLR by clinical and/or endoscopic criteria and admitted to either a medical floor (28) or ICU (26). Patients were then randomized to receive either usual care or pathway care consisting of a standardized orders set to assess stability and expedite discharge. Adverse outcomes (exacerbation of comorbid conditions, rebleeding, need for surgery, death), transfusion requirement and LOS were compared between groups. Phone interviews were conducted 7 and 30 days after discharge. Results: Both groups were similar with respect to age, sex, comorbidities, initial hemoglobin, cause of bleeding, high risk stigmata, and endoscopic therapy. Outcomes were similar between groups (Table). All adverse outcomes were secondary to rebleeding. Only 1 of 54 patients developed an adverse event from 3-14 days from time of admission. Conclusion: 1) LOS of pathway and usual care groups were similar but decreased as compared to pre-pathway care. 2) Adverse outcomes were comparable between groups and uncommon after 48 hours of admission. Background: Clinical pathways for the treatment of upper gastrointestinal hemorrhage (UGIH) have been proposed to standardize care and reduce hospital length of stay (LOS). Previous retrospective studies have shown UGIH treatment pathways to safely decrease LOS in low-risk patients to 2-3 days. Prior to this study, median LOS at our hospital for non-low risk (NLR) UGIH patients was 5 days. Aims: 1) To assess if a clinical pathway decreases LOS in patients with NLR UGIH. 2) To compare rates of adverse outcomes between pathway and usual care in NLR patients with UGIH. Methods: 54 patients with signs of UGIH were assessed in the emergency room and designated as NLR by clinical and/or endoscopic criteria and admitted to either a medical floor (28) or ICU (26). Patients were then randomized to receive either usual care or pathway care consisting of a standardized orders set to assess stability and expedite discharge. Adverse outcomes (exacerbation of comorbid conditions, rebleeding, need for surgery, death), transfusion requirement and LOS were compared between groups. Phone interviews were conducted 7 and 30 days after discharge. Results: Both groups were similar with respect to age, sex, comorbidities, initial hemoglobin, cause of bleeding, high risk stigmata, and endoscopic therapy. Outcomes were similar between groups (Table). All adverse outcomes were secondary to rebleeding. Only 1 of 54 patients developed an adverse event from 3-14 days from time of admission. Conclusion: 1) LOS of pathway and usual care groups were similar but decreased as compared to pre-pathway care. 2) Adverse outcomes were comparable between groups and uncommon after 48 hours of admission.