Clinical guidelines are increasingly being implemented in an attempt to control the rising costs of medical care. The objective of this study was to prospectively evaluate the safety and impact of a clinical practice guideline defining the medically appropriate length of stay for patients with upper gastrointestinal hemorrhage. A previously validated scoring system comprising four independent variables [hemodynamics, time from bleeding, comorbidity, and endoscopic (EGD) findings] was used to identify a subset of patients thought to be at low risk for developing subsequent complications. According to the guideline, patients in the low-risk category were to be discharged within 24 h of achieving low-risk status. The guideline was applied to all adult patients admitted to a 1000-bed, university-affiliated hospital in an alternating month design. Concurrent feedback of a patient's risk score and guideline recommendations were provided to the managing physicians during the 7 intervention months. The guideline and risk stratification tools were not available during the 7 control months. Outcomes surveyors and patients were blinded to study group allocation.
During the 14-month study period, 299 patients were admitted with a diagnosis of upper gastrointestinal hemorrhage, of which 209 achieved low-risk status. Comparison of control and intervention months revealed an increase in guideline adherence from 30–70%, respectively. The improvement in guideline adherence was associated with a decrease in overall length of stay from an average of 4.6–2.9 days and a mean reduction of 1.7 hospital days per patient. No differences were identified between the groups when measured 1 month after discharge with respect to complications, patient health status, or patient satisfaction. Further analysis indicated that early endoscopy, defined as endoscopy on the same day as admission, was an independent predictor of decreased hospital length of stay for patients in the low risk group. (Am J Gastroenterol 1998;93:1384–1385. © 1998 by Am. Coll. of Gastroenterology)
1 University of Illinois College of Medicine at Rockford Rockford Gastroenterology Associates, Ltd. Rockford, IL