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Semiautomated Glasgow-Blatchford Bleeding Score Helps Direct Bed Placement for Patients with Upper Gastrointestinal Bleeding

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Semiautomated Glasgow-Blatchford Bleeding Score Helps Direct Bed Placement for Patients with Upper Gastrointestinal Bleeding Providence St. Joseph Health Providence St. Joseph Health Digital Commons Articles, Abstracts, and Reports 11-1-2020 Semiautomated Glasgow-Blatchford Bleeding Score helps direct bed placement for patients with upper gastrointestinal bleeding. Drew B Schembre Robson E Ely Clinical Transformation, Swedish Medical Center, Seattle, Washington, USA. Janice M Connolly Internal Medicine, Swedish Medical Center, Seattle, Washington, USA. Kunjali T Padhya Gastroenterology, Swedish Medical Center, Seattle, Washington, USA. Rohit Sharda Gastroenterology, Swedish Medical Center, Seattle, Washington, USA. See next page for additional authors Follow this and additional works at: https://digitalcommons.psjhealth.org/publications Part of the Gastroenterology Commons, and the Internal Medicine Commons Recommended Citation Schembre, Drew B; Ely, Robson E; Connolly, Janice M; Padhya, Kunjali T; Sharda, Rohit; and Brandabur, John J, "Semiautomated Glasgow-Blatchford Bleeding Score helps direct bed placement for patients with upper gastrointestinal bleeding." (2020). Articles, Abstracts, and Reports. 4032. https://digitalcommons.psjhealth.org/publications/4032 This Article is brought to you for free and open access by Providence St. Joseph Health Digital Commons. It has been accepted for inclusion in Articles, Abstracts, and Reports by an authorized administrator of Providence St. Joseph Health Digital Commons. For more information, please contact [email protected]. Authors Drew B Schembre, Robson E Ely, Janice M Connolly, Kunjali T Padhya, Rohit Sharda, and John J Brandabur This article is available at Providence St. Joseph Health Digital Commons: https://digitalcommons.psjhealth.org/ publications/4032 Gastrointestinal bleeding Semiautomated Glasgow- Blatchford Bleeding Score helps direct bed placement for patients with upper gastrointestinal bleeding Drew B Schembre ,1 Robson E Ely,2 Janice M Connolly,3 Kunjali T Padhya,4 Rohit Sharda,4 John J Brandabur4 To cite: Schembre DB, ABSTRACT Summary box Ely RE, Connolly JM, et al. Objective The Glasgow- Blatchford Bleeding Score Semiautomated Glasgow- (GBS) was designed to identify patients with upper What is already know about this subject? Blatchford Bleeding gastrointestinal bleeding (UGIB) who do not require Score helps direct bed The Glasgow- Blatchford Bleeding Score (GBS) was hospitalisation. It may also help stratify patients unlikely to ► placement for patients designed to identify low- risk upper gastrointestinal benefit from intensive care. with upper gastrointestinal bleeding (UGIB) patients who could be safely dis- Design We reviewed patients assigned a GBS in the bleeding. BMJ Open Gastro charged from the emergency room. Subsequent emergency room (ER) via a semiautomated calculator. 2020;7:e000479. doi:10.1136/ studies have shown that the GBS can help predict bmjgast-2020-000479 Patients with a score ≤7 (low risk) were directed to an rebleeding and need for transfusion. unmonitored bed (UMB), while those with a score of ≥8 ► Additional material is (high risk) were considered for MB placement. Conformity What are the new findings? published online only. To view with guidelines and subsequent transfers to MB were please visit the journal online ► This study shows that the GBS can be used to iden- reviewed, along with transfusion requirement, rebleeding, (http:// dx. doi. org/ 10. 1136/ tify patients who do not need intensive monitoring bmjgast- 2020- 000479). length of stay, need for intervention and death. after admission. Results Over 34 months, 1037 patients received a GBS in the ER. 745 had an UGIB. 235 (32%) of these patients How might it impact on clinical practice in the Received 18 July 2020 had a GBS ≤7. 29 (12%) low- risk patients were admitted foreseeable future? Revised 13 October 2020 to MBs. Four low- risk patients admitted to UMB required ► Better understanding and use of predictive tools Accepted 23 October 2020 transfer to MB within the first 48 hours. Low- risk patients could help reduce costs and resource allocation as- admitted to UMBs were no more likely to die, rebleed, sociated with treating UGIB. need transfusion or require more endoscopic, radiographic or surgical procedures than those admitted to MBs. No low- risk patient died from GIB. Patients with GBS ≥8 impede access to other critically ill patients. were more likely to rebleed, require transfusion and A recent analysis revealed broad variability interventions to control bleeding but not to die. in ICU admission for UGIB among different Conclusion A semiautomated GBS calculator can be hospitals with no difference in outcomes.2 © Author(s) (or their incorporated into an ER workflow. Patients with a GBS ≤7 employer(s)) 2020. Re- use are unlikely to need MB care for UGIB. Further studies are The Glasgow- Blatchford Bleeding Score permitted under CC BY- NC. No warranted to determine an ideal scoring system for MB (GBS) (online supplemental appendix A) was commercial re- use. See rights admission. designed to identify low-risk patients (score and permissions. Published <1) who could be safely discharged from the by BMJ. 1 emergency room (ER) after presenting with Digestive Health, John Muir BACKGROUND 3 Health, Walnut Creek, California, UGIB. More recent studies have shown that USA Patients with upper gastrointestinal bleeding the GBS can predict a need for endoscopic 4 5 2Clinical Transformation, (UGIB) often present dramatically with intervention, blood transfusion and urgent Swedish Medical Center, haematemesis or melena, hypotension and endoscopy.6 Seattle, Washington, USA even syncope. Because the aetiology of The 2010 Toronto consensus guidelines 3Internal Medicine, Swedish bleeding is usually unknown and behaviour for UGIB advocated risk stratification in the Medical Center, Seattle, 1 Washington, USA uncertain at the time of admission, even ER using the GBS or another validated tool. 4Gastroenterology, Swedish stable patients may be admitted to a high In 2012, the Swedish Medical Center began Medical Center, Seattle, acuity intensive care unit (ICU) with contin- including a GBS for all patients seen in the Washington, USA uous patient monitoring and close nursing ER with suspected UGIB. A ‘smart phrase’ Correspondence to care. However, most patients with GI bleeding was created in the hospital electronic health 1 Dr Drew B Schembre; do not benefit from ICU care. Unneces- record (EHR) (EPIC) to auto-populate rele- [email protected] sary ICU admissions increase costs and may vant fields of the GBS in hope of improving Schembre DB, et al. BMJ Open Gastro 2020;7:e000479. doi:10.1136/bmjgast-2020-000479 1 Open access its use. In addition to identifying very low- risk patients, Table 1 Patients admitted with UGIB the score was also used to stratify lower-risk patients to help reduce unnecessary ICU admissions. Analysis at 6 GBS ≤7 ≥8 P value months revealed an 18% reduction in hospital expenses No 235 510 for UGIB patients, about US$2000 per admission, with Median age 66 71 0.02 no identifiable adverse outcomes, due in large part to Female 45% 50% 0.49 shorter lengths of stay and a decrease in admission to LOS (average in hours) 70 123 <0.01 ICU.7 The current study was undertaken to assess the Unit assignment by 206 (88%) 361 (71%) 0.03 utility of the GBS to direct bed placement for patients protocol with UGIB. Underwent urgent 150 (64%) 457 (90%) 0.01 endoscopy Required transfusion 30 (13%) 360 (71%) <0.01 METHODS: We reviewed all patients over 18 years of age admitted Experienced rebleed 12 (5%) 71 (14%) <0.01 with symptoms of GI bleeding who were assigned a Radiographic or surgical 2 (1%) 19 (4%) 0.03 GBS through Swedish Medical Center’s ER between 1 intervention January 2015 and 31 October 2017. ER physicians were Death 5 (2%) 20 (4%) 0.27 asked to insert a GBS template within the body of their GBS, Glasgow- Blatchford Bleeding Score; LOS, length of stay; admission note in the EHR. The template pulls recent UGIB, upper gastrointestinal bleeding. lab data and vital signs from the EHR to populate blood urea nitrogen, haemoglobin level, systolic blood pressure if they resulted from GI bleeding and whether delay in and pulse. Additional boxes address melena, syncope, any intervention may have contributed to mortality. We heart and liver disease history and are manually entered. compared outcomes among groups who received bed The EHR then calculates a score from 0 to 23 and places assignments within and outside of guidelines. We also it in the note. The score is accompanied by verbiage reviewed a separate cohort of patients during the same suggesting admission to an unmonitored bed (UMB) for period to calculate the actual use of the GBS for patients patients with a score of 1–7, a monitored, intermediate with GIB symptoms. care (IMCU) bed for a score of 8–12 and ICU placement The Fisher’s exact test was used for comparison of for a score of 13 or higher, but also notes that physicians categorical data, and an independent t- test was used may direct patients to a different unit based on clinical for continuous data. Analyses were performed by using judgement, (online supplemental appendix B). GraphPad Prism statistical software, V.8 (GraphPad Soft- Because of major similarities between IMCU and ICU ware, La Jolla, California, USA). A p<0.05 was considered layout, equipment, staffing and other expenses, as well as statistically significant. as frequent flexing of ward designations based on census and staffing, for analysis, admissions to both units were grouped and designated MBs. General medical/surgical RESULTS: ward and telemetry beds were considered UMBs, because Over 34 months, 1037 patients were admitted through of similar staffing levels and cost. the ER with a presumption of GIB and also received a All patients were admitted to hospitalist or intensivist GBS. Of these, 745 had evidence of an UGIB, 244 were services with hospital- based GI consultation. Urgent determined to have had a lower gastrointestinal bleed endoscopy, within 24 hours of admission, was available (LGIB), 23 had evidence of a small bowel bleed and for for all patients regardless of unit.
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