Managing patients with acute, nonvariceal gastrointestinal hemorrhage: development and effectiveness of a clinical care pathway

Abstract

OBJECTIVES: To develop a clinical care pathway for the management of patients with acute upper or lower nonvariceal GI hemorrhage (GIH) who do not require immediate surgical intervention. To test the effectiveness and safety of the pathway in improving the efficiency of care for patients with acute GIH. METHODS: A multidisciplinary team developed the evidence-based GIH clinical care pathway by consensus techniques. In a quasiexperimental design, pathway outcomes were measured prospectively during the first 8 months of pathway implementation, and compared to similar time periods in the 2 prior yr. Effectiveness measures were the number of patients <65 yr of age admitted for GIH and the hospital length of stay for all patients. Thirty-day safety outcomes were the rates of recurrent GIH, mortality, and readmission to hospital for any reason. RESULTS: Of 368 patients studied after pathway implementation, 81 (22%) were managed as outpatients. The number of admissions for pathway patients <65 yr of age was significantly lower compared to 691 prepathway patients ( p < 0.002). Mean length of stay (±95% CI) for pathway inpatients was 3.5 (3.1, 3.9) days, compared to 5.3 (4.9, 5.7) and 4.6 (4.2, 5) days in the 2 prepathway yr, respectively ( p < 0.001). Multivariable regression controlling for admission vital signs, comorbid conditions, age, and the etiology of GIH confirmed that admission after pathway implementation was an independent predictor of a reduced length of hospital stay. There were no significant between-year differences in the 30-day rates of recurrent GIH, mortality, or hospital readmission. CONCLUSION: A multidisciplinary clinical care pathway may improve the efficiency of caring for patients with acute upper or lower nonvariceal GIH. Decreasing the number of admissions for GIH and reducing the hospital length of stay can be achieved without increasing the number of adverse outcomes.