Hay J A, Lyubashevsky E, Elashoff J, Maldonado L, Weingarten S R, Ellrodt A G
Cedars-Sinai Medical Center, The UCLA School of Medicine, Los Angeles, California, USA.
Am J Med. 1996 Mar;100(3):313-22. doi: 10.1016/s0002-9343(97)89490-9.
Physicians lack objective outcome data to define the medically appropriate length of stay (LOS) for patients hospitalized with acute upper gastrointestinal hemorrhage (UGIH), resulting in wide variations in resource utilization and quality of care. A clinical practice guideline with the ability to assign relative risk for adverse events is proposed.
A comprehensive scoring system was derived from the literature by using four variables; hemodynamics, time from bleeding, comorbidity, and esophagoduodenoscopy findings. The discriminatory ability, potential safety, and impact on resource utilization of the clinical practice guideline was measured in a retrospective, observational study.
Seventy percent of UGIH patients (349 of 500) achieved low-risk status according to the guideline, and, were therefore potentially suitable for early discharge from the hospital. If low-risk patients were discharged based upon the guideline, mean (+/- SD) hospital LOS would have been decreased from 4.8 +/- 2.4 days to 2.7 +/- 1.4 days; mean reduction was 2.1 bed-days per patient (95% CI 1.8 to 2.3, P <0.001). LOS would have increased in 4% of cases. Adopting the guideline's recommendation of early discharge would have resulted in a 0.6% (95% CI 0.07 to 2.1) complication rate, with no worsening of quality of care, as judged by implicit review.
The proposed clinical practice guideline may safely reduce hospital LOS for selected low-risk patients with acute UGIH. Moreover, it also may reduce premature discharge of high-risk patients prone to life-threatening events.
医生缺乏客观的预后数据来确定急性上消化道出血（UGIH）住院患者的合理住院时长（LOS），这导致资源利用和医疗质量存在很大差异。本文提出了一种能够对不良事件进行相对风险评估的临床实践指南。
通过对血流动力学、出血时间、合并症和食管十二指肠镜检查结果这四个变量进行文献研究，得出了一个综合评分系统。在一项回顾性观察研究中，对该临床实践指南的鉴别能力、潜在安全性以及对资源利用的影响进行了评估。
根据该指南，70%的UGIH患者（500例中的349例）达到低风险状态，因此有可能适合提前出院。如果依据该指南让低风险患者出院，平均（±标准差）住院时长将从4.8±2.4天降至2.7±1.4天；每位患者平均减少2.1个床日（95%置信区间为1.8至2.3，P<0.001）。4%的病例住院时长会增加。采用该指南关于提前出院的建议，并发症发生率将为0.6%（95%置信区间为0.07至2.1），通过隐性评估判断，医疗质量并未恶化。
所提出的临床实践指南可能会安全地缩短部分低风险急性UGIH患者的住院时长。此外，它还可能减少易发生危及生命事件的高风险患者的过早出院情况。
