ORIGINAL ARTICLES

Evaluation of the need for endoscopy to identify low-risk patients presenting with an acute upper gastrointestinal bleed suitable for early discharge

G G Robins¹, M S Sarwar², M Armstrong¹, M E Denyer¹, S Bush³, T Hassan⁴ and S M Everett⁵

¹ Department of Gastroenterology, St James’s University Hospital, Leeds LS9 7TF, UK
² Department of Gastroenterology, Victoria Infirmary, Glasgow G42 9TY, UK
³ Department of Emergency Medicine, St James’s University Hospital, Leeds LS9 7TF, UK
⁴ Department of Emergency Medicine, Leeds General Infirmary, Leeds LS1 3EX, UK
⁵ Centre for Digestive Diseases, Leeds General Infirmary, Leeds LS1 3EX, UK

Correspondence to:
Dr G Robins, Level 7, Clinical Sciences Building, St James’s University Hospital, Leeds LS9 7TF, UK; medggr{at}leeds.ac.uk

Aims: To audit the safety of differing protocol-driven early-discharge policies, from two sites, for low-risk acute upper gastrointestinal (GI) bleeding and determine if default early (<24 h) in-patient endoscopy is necessary.

Methods: All patients with low-risk acute upper GI bleeding presenting to two separate hospital sites in Leeds from August 2002 to March 2005 were identified. Both hospitals operate nurse-led process-driven protocols for discharge within 24 h, but only one includes default endoscopy. Relevant information was obtained from patients’ notes, patient administration systems, discharge letters and endoscopy records.

Results: 120 patients were admitted to site A and 74 to site B. Median length of stay on the clinical decisions unit was 12.6 h at site A and 9.4 h at site B (p = 0.045). Oesophagogastroduodenoscopy was performed on 89/120 (74%) patients at site A compared with only 7/74 (9%) at site B (p<0.001). Six of 120 (5%) patients from site A were admitted to hospital for further observation compared with 6/74 (8%) from site B (p = 0.38). Of the remaining patients, all were discharged within 24 h, and 8/114 (7%) at site A vs 17/68 (25%) at site B were given hospital clinic follow-up (p<0.001). None of the 194 patients had further bleeding or complications within 30 days.

Conclusions: Patients admitted with a low-risk acute upper GI bleeding can be managed safely by a nurse-led process-driven protocol, based on readily available clinical and laboratory variables, with early discharge <24 h. Avoiding in-patient endoscopy appears to be safe but at the price of greater clinic follow-up.

Abbreviations: CDU, clinical decisions unit; GI, gastrointestinal; OGD, oesophagogastroduodenoscopy

Keywords: discharge protocol; emergency medicine; endoscopy; gastrointestinal haemorrhage

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