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Critical Care |

A Triage Policy for Patients With Upper Gastrointestinal Bleed: Who Needs The ICU?

Rebecca Sternschein, MD; Sharon Leung, MD; Lewis Eisen, MD; Ariel Shiloh, MD
Author and Funding Information

Montefiore Medical Center/Albert Einstein College of Medicine, Division of Critical Care, Department of Medicine, Bronx, NY


Chest. 2013;144(4_MeetingAbstracts):364A. doi:10.1378/chest.1704249
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Abstract

SESSION TITLE: Critical Care Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Upper gastrointestinal bleeding (UGIB) is a common ICU admission. Appropriate triage is vital for effective resource utilization. We generated a triage policy based on end-organ damage, without endoscopic results, and compared it to a traditional scoring system, the Rockall score (RS). In the absence of ongoing bleeding, patients were only admitted to ICU if end-organ damage was present or patients had respiratory failure or shock. The purpose of this study is to assess the outcomes of patients with UGIB with and without ICU admission.

METHODS: We conducted a retrospective cohort study of patients with UGIB presenting to the emergency department for whom a critical care consult was requested. Cirrhosis, sepsis, and lower gastrointestinal bleeding were excluded. Patient characteristics, markers of end-organ damage (lactate, creatinine, INR), triage vitals, nadir hemoglobin in the first 24 hours, endoscopy results, clinical (pre-endoscopy) and complete (post-endoscopy) RS and survival were examined.

RESULTS: Between January 2011 and January 2013, a total of 172 patients were identified, 67 patients (39.2%) were admitted to ICU. The mean time of critical care consults performed were 19.2 hours earlier than endoscopy. There was no difference between cohorts with mean clinical RS (ICU 4.50 vs ward 4.57, p=0.82), complete RS (ICU 5.76 vs ward 5.72, p=0.90), or mortality (ICU 10% vs ward 8.5%, p=0.79). In-hospital mortality was 9.3%. There was no difference in mortality of high-risk complete RS (ICU 10.6% vs. ward 7.8%, p=0.75) or high-risk endoscopic lesions (ICU 5.6%vs. ward 6.9% p=0.99). Multivariate analysis, demonstrated elevated lactate was an independent risk factor of death (odds ratio 1.35 [95% CI (1.09, 1.67); p=0.006]) after controlling for age >65 years, gender, and RS. ICU was not a protective factor for mortality (odds ratio 0.75 [95% CI (0.15, 3.70); p=0.73].

CONCLUSIONS: Triage based on end-organ damage is effective, allowing for less delay and effective ICU utilization.

CLINICAL IMPLICATIONS: In this retrospective cohort study, we were not able to demonstrate survival benefits with ICU admission.

DISCLOSURE: The following authors have nothing to disclose: Rebecca Sternschein, Sharon Leung, Lewis Eisen, Ariel Shiloh

No Product/Research Disclosure Information


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