Does this patient have a severe upper gastrointestinal bleed?

CONTEXT: Emergency physicians must determine both the location and the severity of acute gastrointestinal bleeding (GIB) to optimize the diagnostic and therapeutic approaches. OBJECTIVES: To identify the historical features, symptoms, signs, bedside maneuvers, and basic laboratory test results that distinguish acute upper GIB (UGIB) from acute lower GIB (LGIB) and to risk stratify those patients with a UGIB least likely to have severe bleeding that necessitates an urgent intervention. DATA SOURCES: A structured search of MEDLINE (1966-September 2011) and reference lists from retrieved articles, review articles, and physical examination textbooks. STUDY SELECTION: High-quality studies were included of adult patients who were either admitted with GIB or evaluated in emergency departments with bedside evaluations and/or routine laboratory tests, and studies that did not include endoscopic findings in prediction models. The initial search yielded 2628 citations, of which 8 were retained that tested methods of identifying a UGIB and 18 that identified methods of determining the severity of UGIB. DATA EXTRACTION: One author abstracted the data (prevalence, sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality, with confirmation by another author. Data were combined using random effects measures. DATA SYNTHESIS: The majority of patients (N = 1776) had an acute UGIB (prevalence, 63%; 95% CI, 51%-73%). Several clinical factors increase the likelihood that a patient has a UGIB, including a patient-reported history of melena (LR range, 5.1-5.9), melenic stool on examination (LR, 25; 95% CI, 4-174), a nasogastric lavage with blood or coffee grounds (LR, 9.6; 95% CI, 4.0-23.0), and a serum urea nitrogen:creatinine ratio of more than 30 (summary LR, 7.5; 95% CI, 2.8-12.0). Conversely, the presence of blood clots in stool (LR, 0.05; 95% CI, 0.01-0.38) decreases the likelihood of a UGIB. Of the patients clinically diagnosed with acute UGIB, 36% (95% CI, 29%-44%) had severe bleeding. A nasogastric lavage with red blood (summary LR, 3.1; 95% CI, 1.2-14.0), tachycardia (LR, 4.9; 95% CI, 3.2-7.6), or a hemoglobin level of less than 8 g/dL (LR range, 4.5-6.2) increase the likelihood of a severe UGIB requiring urgent intervention. A Blatchford score of 0 (summary LR, 0.02; 95% CI, 0-0.05) decreases the likelihood that a UGIB requires urgent intervention. CONCLUSIONS: Melena, nasogastric lavage with blood or coffee grounds, or serum urea nitrogen:creatinine ratio of more than 30 increase the likelihood of a UGIB. Blood clots in the stool make a UGIB much less likely. The Blatchford clinical prediction score, which does not require nasogastric lavage, is very efficient for identifying patients who do not require urgent intervention.

Clinical Performance of Prediction Rules and Nasogastric Lavage for the Evaluation of Upper Gastrointestinal Bleeding: A Retrospective Observational Study.

Introduction. The majority of patients with acute upper gastrointestinal bleeding (UGIB) are admitted for urgent endoscopy as it can be difficult to determine who can be safely managed as an outpatient. Our objective was to compare four clinical prediction scoring systems: Glasgow Blatchford Score (GBS) and Clinical Rockall, Adamopoulos, and Tammaro scores in a sample of patients presenting to the emergency department of a large US academic center. Methods. We performed a retrospective cohort study of patients during 2008-2010. Our outcome was significant UGIB defined as high-risk stigmata on endoscopy, or receipt of blood transfusion or surgery, or death. Results. A total of 393 patients met inclusion criteria. The GBS was the most sensitive for detecting significant UGIB at 98.30% and had the highest negative predictive value (90.00%). Adding nasogastric lavage data to the GBS increased the sensitivity to 99.57%. Conclusions. Of all four scoring systems compared, the GBS demonstrated the highest sensitivity and negative predictive value for identifying a patient with a significant UGIB. Therefore, patients with a 0 score can be safely managed as an outpatient. Our results also suggest that performing a nasogastric lavage adds little to the diagnosis UGIB.

Variability in resource use: diagnosing colorectal cancer.

OBJECTIVES: Efficient resource use is relevant in all healthcare systems. Although colorectal cancer is common, little has been published regarding the utilization of clinical resources in diagnosis. STUDY DESIGN: The primary aim was to evaluate the patterns and factors associated with clinical services used to diagnose colorectal cancer at 14 US Department of Veterans Affairs facilities. The secondary aim was to investigate whether using more clinical services was associated with time to diagnosis. METHODS: We reviewed medical records for 449 patients with colorectal cancer in an observational study. Study end points were the use of clinical diagnostic services grouped as laboratory tests, imaging studies, and subspecialty consultations. Cumulative logistic regression models were used to explore factors associated with each outcome. RESULTS: Facility variability contributed to the variability of resource use in all models. In adjusted analyses, older patients had higher use of laboratory tests (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.02-1.43) and incidentally discovered colorectal cancer was associated with increased use of consultations (OR, 1.97; 95% CI, 1.27-3.05), imaging studies (OR, 1.70; 95% CI, 1.12-2.58), and laboratory tests (OR, 3.14; 95% CI, 2.06-4.77) compared with screen-detected cancers. There was a strong direct correlation between thenumber of diagnostic services performed and the median time to diagnosis (Spearman correlation coefficient, 0.99; P < .001). CONCLUSIONS: Variability in utilization of diagnostic clinical services was associated with patient age, patient presentation, and facility. Increased resource use was highly correlated with increased time to diagnosis.

A comparative resident site visit project: a novel approach for implementing programmatic change in the duty hours era.

The Duke University Medical Center Internal Medicine Residency Program did not reach its anticipated quota of applicants during the 2008 National Residency Matching Program. Post-Match feedback regarding workload prompted an effort to redesign the general medicine service. As part of that effort, Duke program leaders sought to learn how peer programs accommodated Accreditation Council for Graduate Medical Education (ACGME) regulations. They launched the Resident Site Visit Project (RSVP).In 2008, Duke resident teams visited six other academic internal medicine residency programs based in university hospitals in the eastern United States. They conducted a systematic survey using a standardized questionnaire, interviewed program leaders and residents, and observed workflow directly. The RSVP identified strategies for accommodating ACGME rules in service design and also highlighted challenges shared by all of the programs.Discussion of the shared challenges yielded six core principles that directly guided Duke's general medicine service redesign: emphasize patient safety, reduce resident work compression, create educational opportunities, ensure automatic duty hours compliance, preserve essential program attributes, and involve stakeholders in the process of change.The Duke RSVP is an approach to programmatic change that applies information collected during site visits in defining core principles for program redesign. Collaboration between programs through resident site visits facilitates innovation, creates a foundation for change that increases stakeholder involvement, and generates opportunities for multicenter research.