Hay J A, Maldonado L, Weingarten S R, Ellrodt A G
HealthCare Partners Medical Group, Pasadena, CA 91105, USA.
JAMA. 1997;278(24):2151-6.
Upper gastrointestinal tract hemorrhage (UGIH) is a common and potentially life-threatening disorder. Resource utilization can vary without adverse effect on patient outcome. Clinical practice guidelines are a potential solution to reduce variation in practice while improving patient outcomes.
To validate prospectively the safety, acceptability, and impact of a clinical practice guideline defining the medically appropriate length of stay (LOS) for patients hospitalized with UGIH.
Prospective, controlled time-series study with an alternate-month design. Outcome surveyors and patients were blinded to study group allocation. GUIDELINE: A retrospectively validated scoring system using 4 independent variables: hemodynamics, time from bleeding, comorbidity, and esophagogastroduodenoscopy (EGD) findings to predict risk of adverse events. The quantitative risk for the low-risk subset was 0.6% (95% confidence interval [CI], 0.0%-2.0%) for subsequent complications and 0% (95% CI, 0.0%-0.9%) for life-threatening complications from this retrospective evaluation.
A 1000-bed, not-for-profit, university-affiliated teaching hospital.
Consecutive adult patients hospitalized for acute UGIH.
Concurrent feedback of guideline recommendation (same-day hospital discharge) to physicians caring for patients at low risk for complication. No risk information was provided during control months.
Seventy percent (209/299) of UGIH patients achieved low-risk status according to the guideline and were therefore potentially suitable for early discharge from the hospital. Providing real-time quantitative risk information (intervention group only) was associated with an increase in guideline compliance from 30% to 70% (P<.001) and a decrease in mean (SD) LOS from 4.6 (3.5) days to 2.9 (1.3) days (mean reduction of 1.7 days per patient; P<.001). No differences in complications, patient health status, or patient satisfaction were found when measured 1 month after discharge. An independent variable predicting decreased hospital LOS for low-risk UGIH patients was early EGD.
Implementation of the clinical practice guideline safely reduced hospital LOS for selected low-risk patients with acute UGIH. Further prospective validation in other settings is warranted.
上消化道出血（UGIH）是一种常见且可能危及生命的疾病。资源利用情况可能各不相同，但对患者预后无不良影响。临床实践指南是减少实践差异同时改善患者预后的一种潜在解决方案。
前瞻性验证一项临床实践指南的安全性、可接受性及影响，该指南规定了因UGIH住院患者的合理住院时长（LOS）。
采用隔月设计的前瞻性对照时间序列研究。结局测量人员和患者对研究组分配情况不知情。
一种回顾性验证的评分系统，使用4个独立变量：血流动力学、出血时间、合并症以及食管胃十二指肠镜检查（EGD）结果来预测不良事件风险。根据该回顾性评估，低风险亚组发生后续并发症的定量风险为0.6%（95%置信区间[CI]，0.0% - 2.0%），发生危及生命并发症的风险为0%（95%CI，0.0% - 0.9%）。
一家拥有1000张床位的非营利性大学附属医院。
因急性UGIH住院的成年连续患者。
向负责护理并发症低风险患者的医生同时反馈指南建议（当日出院）。在对照月份不提供风险信息。
根据指南，70%（209/299）的UGIH患者达到低风险状态，因此有可能适合早期出院。提供实时定量风险信息（仅干预组）使指南依从性从30%提高到70%（P <.001），平均（标准差）住院时长从4.6（3.5）天降至2.9（1.3）天（每位患者平均减少1.7天；P <.001）。出院1个月后测量，并发症、患者健康状况或患者满意度方面未发现差异。预测低风险UGIH患者住院时长缩短的一个独立变量是早期EGD。
临床实践指南的实施安全地缩短了部分急性UGIH低风险患者的住院时长。有必要在其他环境中进行进一步的前瞻性验证。
