Patel R, Clancy R, Crowther E, Vannahme M, Pullyblank A
Department of Colorectal Surgery, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK.
Colorectal Dis. 2014 May;16(5):377-81. doi: 10.1111/codi.12524.
Acute lower gastrointestinal bleeding (LGIB) is a common cause of emergency admissions yet rarely requires blood transfusion or radiological/surgical intervention. We aimed to develop a risk assessment tool to identify patients with acute LGIB who can be safely managed in primary care.
We retrospectively applied an existing nomogram to 20 admissions to obtain criteria that could predict the need for transfusion. We simplified the algorithm to three criteria and developed an associated care pathway. If haemoglobin was > 13 g/dl, systolic blood pressure > 115 mmHg and the patient was not anticoagulated, admission could be avoided. These criteria were then applied to 57 prospective patients attending during a 16-week period. This was implemented with education of primary and secondary care staff, access to an emergency clinic and provision of patient information.
We applied our algorithm and care pathway to 57 patients with uncomplicated rectal bleeding. Thirty-five per cent (20/57) of potential admissions were avoided. Instead, patients received written information and underwent flexible sigmoidoscopy as outpatients within 6 weeks. One discharged patient was readmitted from endoscopy with severe colitis. There were no other readmissions or complications. Of the 36 patients for whom the algorithm predicted admission was needed, 33% (12/36) were anticoagulated, 94% (34/36) had haemoglobin < 13 g/dl and 42% (15/36) had a systolic blood pressure < 115 mmHg. Only one admission (1.8%) did not fulfil the admission criteria and could have potentially been avoided. Avoidable admissions reduced from 50 to 1.8%.
The application of a simple rectal bleeding algorithm can safely prevent unnecessary admissions.
急性下消化道出血（LGIB）是急诊入院的常见原因，但很少需要输血或进行放射学/外科干预。我们旨在开发一种风险评估工具，以识别可在基层医疗中安全管理的急性LGIB患者。
我们对20例入院病例回顾性应用现有的列线图，以获得可预测输血需求的标准。我们将该算法简化为三个标准，并制定了相关的护理路径。如果血红蛋白>13g/dl、收缩压>115mmHg且患者未接受抗凝治疗，则可避免入院。然后将这些标准应用于16周内就诊的57例前瞻性患者。这一过程通过对基层和二级医疗人员的培训、设立急诊诊所及提供患者信息来实施。
我们将算法和护理路径应用于57例单纯直肠出血患者。35%（20/57）的潜在入院得以避免。相反，患者收到书面信息，并在6周内作为门诊患者接受了乙状结肠镜检查。一名出院患者在内镜检查后因严重结肠炎再次入院。没有其他再次入院或并发症发生。在算法预测需要入院的36例患者中，33%（12/36）接受了抗凝治疗，94%（34/36）的血红蛋白<13g/dl，42%（15/36）的收缩压<115mmHg。只有一例入院（1.8%）不符合入院标准，本可避免。可避免的入院率从50%降至1.8%。
应用简单的直肠出血算法可安全地避免不必要的入院。
