NICE have recently published new guidance on Upper GI bleeding.
It is surprisingly sensible. I was pleased with their position on PPI’s for upper GI bleeding (not before endoscopy…).
The other point that I was happy to see was the inclusion of the Blatchford score for risk assement of these patients.
We all love a good scoring system, especially if really complicated (long hours spent working out APACHE scores on ICU spring to mind)
The Blatchford score however, is simple, and useful. I have been using this to help plan management of these patients for a while, and I was surprised to find that many people have not heard of it.
So what else to do? To the
Bat Cave St Emlyn’s!
What is it?
To give it its full name; The Glasgow Blatchford Score was derived in 2000. It is designed to identify patients who require admission for treatment of their UGI bleed, and who can go home for outpatient management.
Previous to this, standard practice was to admit the mass majority of these patients, even the young well ones with minor bleeding or ‘coffee ground’vomits.
Here it is:
It can be easily calcualted using information availble in the ED. You can use the ever useful mdcalc.com
So why use it?
So we can send people home! This has to be a good thing, as long as it is ‘safe’ to do so.
In 2009 Stanley et al performed a prospective study to establish whether this was the case. Their hypothesis: If the GB score was 0, the patient could go home from the ED, and be followed up as an outpatient.
Sounds great right? Did it work?
The study was split into two parts. First they collected data on all GI bleeds seen in the ED. They recorded the outcomes, and compared the outcomes with the GB score on admission. In the second part they introduced the low risk criteria, and discharged those with a GB score of 0.
In the first part they identified 334 patients with UGI bleed. 319 of them got admitted (96%)
53 of them were low risk (GBS 0). 50 of these were admitted. None of them died or needed any interventions.
So far so good yes? If we could have have sent those patients home, wouldn’t everyone be happier and the world a better place?
So that’s what they did. In the second phase of the study they put their theory in practice. They identified 491 UGI bleed patients. 123 (22%) of them presented with a GBS score of 0, and of this group, 84 got sent home (68%).
They then followed them up to see how they got on. Only 23 (40%) turned up for their outpatient endoscopy, the rest were chased up via GP, case note review and telephone follow up.
So how did they do? Really well as it turns out. Out of the 123 patients with a GBS score of 0 a total of 0 needed an intervention or died from a UGI bleed related cause in the following 6 months. Zero, zilch, nada.
These results are summarised here:
For those concerned with our limited health resources (i.e. all of us), the exciting figure is at the bottom. Before the scoring system was introduced, only 4% of the UGI bleed patients were being discharged from the ED. With the scoring system in place, 29% were sent home.
Considering the numbers of these patients we all see, this is a big deal.
So should we do this? I think so.