Discussion

GI bleeding represents the most common cause for admission to hospital GI services in the USA, accounting for up to 500 000 admissions per year8 with 1.9% all-cause mortality.9 Many UGIB patients present with some degree of haemodynamic instability. Uncertainty about the source of bleeding combined with the spectre of rapid deterioration can lead to ICU admission. Most of these patients however never need specialised ICU services such as intubation, central monitoring or urgent cardioversion. ICU and other MBs demand significantly more resources than UMBs and may be a scarce commodity in some hospitals. Admission to an ICU may also lead to more invasive procedures and longer length of stay, without necessarily producing better outcomes.2 ICU admissions for UGIB vary widely in the USA. A recent study of 94 acute care, non-federal hospitals showed that ICU admission rates for UGIB ranged from 11.5% to 51.2%, without any demonstrable difference in mortality.2 Another study estimated that up to 40% of ICU admissions for UGIB are unnecessary.10

In our own institution, the expense of (not charge for) an ICU bed is about 2.5 times that of an UMB. A step-down or IMCU bed is almost as expensive at about twice the price of an UMB. This is driven largely by higher staffing costs for both units. The level of care in the Swedish IMCU resembles ICU care in many hospitals with large, glass fronted individual rooms with central, remote monitoring and patient to nurse ratios that do not exceed 3:1. In fact, IMCU and ICU rooms are identical and differ in designation only when staffing levels change. In this study, because of the similar costs and level of care provide in ICU and IMCU and frequent shifting of patients between the two units for non-medical reasons, we chose to combine admissions to these two units and compare them to admissions to UMBs, specifically for lower-risk patients. Most patients in this study who were admitted to MBs were actually admitted to IMCU rather than ICU (315 vs 75 or 81%). We felt that because of the broad variation in design and staffing of ICUs and other MBs among different institutions, a clearer distinction in cost and care could be drawn between monitored and UMBs rather than among multiple different levels of monitoring and care. The goal was not so much to determine whether the GBS identifies an ideal level of care for each person, but rather to see if a score exists below which monitored care may not be necessary.

The decision to direct patients with a GBS ≤7 to an UMB was not arbitrary. Preventing morbidity and mortality that might result from haemodynamic compromise remains the primary goal of admitting UGIB patients to an MB. A patient in an MB can receive rapid transfusion and fluid replacement, vasopressor support and in extreme cases, undergo intubation and cardioversion. In addition, close nursing support and constant haemodynamic monitoring can theoretically identify sequalae of bleeding more rapidly. But studies suggest that rapid blood loss is unlikely at GBS ≤7. Bryant et al11 reviewed 888 patients with UGIB and found no patient who needed endoscopic or surgical intervention had an admission GBS below 8. Chatten et al12 reviewed 399 patients with UGIB and found that over 92% of patients with a GBS ≤8 did not need endoscopic therapy. Robertson et al13 in a study of 424 patients with UGIB suggested that a GBS of 9 for requiring ICU admission (88% sensitive and 44% specific) and a score of 10 was 76% sensitive and 86% specific for needing transfusion. A cut-off of 7 was felt to exclude the vast majority of patients with active, haemodynamically significant bleeding requiring aggressive support. Ready access to endoscopic diagnosis and intervention for patients in UMBs as well as ability to rapidly transfer deteriorating or unstable patients to an MB provided additional reassurance. Internal review of 6 months of patient with GBS ≤7 also suggested safety at this level.

This study demonstrates that the GBS can identify a threshold below which the likelihood of sudden deterioration from bleeding is very low. In the study population, low-risk patients accounted for about a third of those admitted with UGIB. Despite guidelines, 12% of low-risk patients were admitted to MBs. Caution appears to have driven most of these decisions. Despite a higher level of care, the treatments and outcomes for these patients did not differ significantly from those admitted to UMBs. Two patients required intubation yet both died. It is impossible to tell if any of the surviving patients benefited from the higher level of nursing care or haemodynamic monitoring. While five low-risk patients ultimately died and four others were transferred to MBs, none was the direct result of bleeding. It is not surprising and ultimately appropriate that some very elderly patients or those with terminal conditions were not placed in MBs as aggressive interventions would likely not have changed outcomes. Transfers to MBs that did occur were timely and no adverse outcomes appeared to have resulted from primary UMB placement.

The GBS alone proved less effective for identifying those who truly need an MB. Evidence-based guidelines have suggested that haemodynamically unstable patients and those with GBS ≥12 may benefit from endoscopy as early as 12 hours after admission.14–17 Although formal guidelines for ICU care for this group are lacking, it might be assumed that patients unstable enough to benefit from very early endoscopy would also benefit from the highest level of care. However, a small subgroup of 16 patients with a GBS ≥13 did as well in UMBs as those in MBs. These patients tended to have higher scores due to renal failure or severe anaemia but were otherwise haemodynamically stable.

Roughly half of all UGIB patients had a GBS between 8 and 12. One-third of these patients did well in UMBs and likely others would have as well. However, 10 (8%) patients in this group, initially felt by the ER physician to be low risk, required transfer to an MB. Four had respiratory compromise or aspiration while two developed mental status changes associated with alcohol withdrawal or cirrhosis. Two of these patients ultimately died but neither from ongoing bleeding. Seven other deaths occurred among patients with scores between 8 and 10, despite primary admission to an MB. This is consistent with the findings of other studies that UGIB patients at highest risk of mortality suffer from comorbidities such as alcohol withdrawal, cirrhosis, and cancer6 and rarely die directly from bleeding.18 The large number of high-risk patients (32%) who were successfully treated in UMBs suggests that other factors not captured by the GBS such as age, alcohol withdrawal or respiratory compromise should be considered when making bed selection and that the absence of these conditions may enable safe UMB placement for UGIB patients with a GBS ≥8. What the safe GBS upper limit might be and what other factors may be necessary predict safe UMB placement are not identified in this study.

While risk assessment tools aid ICU decision making for other conditions,19–21 none of the half dozen common risk tools for GI bleeding are widely used for this purpose.12 22 23 The Rockall Score, Baylor Bleeding Score and Cedars-Sinai Predictive Index rely in part on endoscopic elements that are generally not available to the ER physician.24 The GBS, the AIMS65 score as well as the clinical Rockall score rely only on vital signs, labs and historical elements that are almost always available in the first hours of evaluation. The GBS has been shown to help predict need for urgent endoscopy13 and blood transfusion,20 two factors that might suggest a need for higher level of care,5 but has not been previously reported as a tool for bed assignment. The GBS remains the most widely studied risk stratification tool for UGIB and appears to be more sensitive than either of the Rockall scores.4 20

The AIMS65 score, which incorporates age and albumin level but not subjective or historical elements like syncope and liver disease, appears to be more accurate for predicting mortality and length of stay,25 but may be less accurate than the GBS for predicting recurrent bleeding or transfusion requirement.26 27 However, predicting death in patients with advanced age and multiple comorbidities may not clearly translate into better outcomes with early MB admission. The AIMS65 score is easier to memorise and calculate than the GBS, but this advantage fades when the EHR automates it.

Despite recommendations to incorporate them into decision making in the ER, risk scores are not used widely.1 Many physicians feel that risk scores are not particularly useful or don’t work any better than an ER physician’s judgement.28 29 It may also be that even simple scores require too much effort to remember and apply than most busy physicians are willing to invest.

This study shows that by leveraging the data grabbing functions of an EHR, the GBS can be easily incorporated into the ER assessment. But even this feature did not lead to rapid adoption. Only after months of intense education did ER physicians begin to use the GBS calculator regularly, and even then, not consistently. However, once adopted, the GBS began to serve as an efficient short hand among ER physicians, hospitalists and gastroenterologists, replacing a long list of vital signs and labs with a simple, widely understood number.

Because the source of GI bleeding is often unclear at presentation, the ideal risk score would have utility for LGI bleeding as well. While several scores have been proposed to predict mortality and other outcomes for patients with LGI bleeding, studies have emerged showing that the GBS has reasonable accuracy for identifying low-risk patients with LGI bleeding.30 31 This study supports those findings and demonstrates that the GBS may effectively identify low-risk patients with LGI bleeding safe for UMBs. A total of 244 patients who were ultimately found to have had lower GI bleeding had a bleeding score calculated at admission. The GBS directed 117 of 133 (88%) low-risk patients to UMBs. None of these patients suffered an adverse event or poor outcome as a result of their bed placement. Four low-risk patients were transferred to MBs within 48 hours. Three who were transferred out of caution due to cirrhosis, alcohol withdrawal and ongoing bleeding were discharged within 48 hours of transfer. One patient with a diverticular source continued to bleed despite angiography and ultimately underwent haemicolectomy.

Any cost savings from using the GBS remains unknown. An earlier review at our institution of 166 UGIB patients revealed that using the GBS along with other elements aimed at improving physician communication decreased ICU admissions by 42%, LOS by 14% and hospital expense by 18%.7 Chang and Shapiro estimated that if ICU care for UGI bleeding patients in higher utilisation hospitals were reduced to levels of lower utilisation hospitals, total costs would drop by about 6.5%.2

Several elements limit this study. First, the GBS for bed placement is limited because it does not take into account comorbidities and risk factors beyond GI bleeding. Many low-risk patients were admitted to MBs based on ER physicians’ concerns about other conditions and less than a third were redirected based on a concern about bleeding. Two who died succumbed to respiratory complications without rebleeding and none in this group needed aggressive haemodynamic interventions to control bleeding. But there is no way of knowing whether this small group would have done as well in UMBs. However, this does demonstrate the real world applicability of these guidelines; physicians had no problem admitting outside of guidelines when a patient appeared at higher risk.

Just under a fifth of patients with signs of UGI bleeding did not undergo endoscopy during the index admission. Although all had a diagnostic endoscopy within the last year, the true cause of these bleeds was not documented. The number and types of endoscopic interventions are also not captured in this data, nor are the final diagnoses, incidence of liver disease and bleeding source for all patients. While more granular data may help us better understand which patients are ultimately more likely to rebleed or do poorly, the source of the bleed is almost always obscure at the time of admission and the presence of cirrhosis may also be unknown. The ideal risk score should aid in placement without having to know the source of bleeding if no diagnostic or interventional endoscopy is necessary. In this study, two individuals in the lower-risk group were admitted to MBs because of a concern for varices and one other who was found to have non-bleeding varices after index endoscopy was transferred to the ICU for observation. Others may have had cirrhosis that was not initially identified but did not lead to deterioration or require MB transfer.

During the study period, up to 37% of patients with UGIB may have been missed because some ER physicians did not use the automated system. However, it does not appear that any specific risk groups were excluded. This suggests that, although incomplete, the cohort was representative of patients who present with UGIB. The study also does not look at hospital readmissions or post hospital deaths, although an adverse effect from improper bed placement would likely become apparent during that admission and not after discharge. Some subgroup analyses involve small numbers of patients, limiting the ability to demonstrate differences.

The findings of this study may not be universally applicable. Hospitals, their staffs and their skill sets differ. While patients with a score of 7 may consistently do well in an UMB at a facility where access to endoscopy is easy and ICU beds plentiful, the same may not be true for smaller hospitals with fewer ICU beds and inconsistent specialty coverage. Similarly, some facilities may not have ready access to a 24-hour endoscopy unit and depend on MBs for urgent endoscopy. Although it appears that a GBS ≤7 predicts a low risk of deterioration, a hospital’s unique profile and ability to manage these problems should determine cut-off levels for MB placement or transfer.