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Improved outcomes following implementation of an acute gastrointestinal bleeding multidisciplinary protocol

Loftus, Tyler J. MD; Go, Kristina L. MD; Hughes, Steven J. MD; Croft, Chasen A. MD; Smith, Robert Stephen MD; Efron, Philip A. MD; Moore, Frederick A. MD; Brakenridge, Scott C. MD; Mohr, Alicia M. MD; Jordan, Janeen R. MD

Journal of Trauma and Acute Care Surgery: July 2017 - Volume 83 - Issue 1 - p 41–46
doi: 10.1097/TA.0000000000001295
EAST Plenary Paper

BACKGROUND Effective multidisciplinary management of gastrointestinal bleeding (GIB) requires effective communication. We instituted a protocol to standardize communication practices with the hypothesis that outcomes would improve following protocol initiation.

METHODS We performed a retrospective cohort analysis of 442 patients who required procedural management of acute GIB at our institution during a 50-month period spanning 25 months before and 25 months after implementation of a multidisciplinary communication protocol. The protocol stipulates that when a patient with severe GIB is identified, a conference call is coordinated among the gastroenterology, interventional radiology, and acute care surgery teams. A consensus plan is generated and then reassessed following procedural interventions and changes in patients' status. Patients' characteristics, management strategies, and outcomes were compared before and after protocol initiation.

RESULTS Patient populations before and after protocol initiation were similar in age, comorbidities, outpatient use of antiplatelet/anticoagulant medications, admission vital signs, and admission laboratory values. The median interval between admission and the first procedure was significantly shorter in the protocol group (40 vs 47 hours, p = 0.046). The proportion of patients who received packed red blood cell transfusions decreased following protocol initiation (41% vs 50%, p = 0.018). Median hospital length of stay was significantly shorter in the protocol group (5.0 vs 6.0 days, p = 0.014). Readmissions with GIB were decreased after protocol implementation (8% vs. 15%, p = 0.023).

CONCLUSION Implementation of a multidisciplinary protocol for management of acute GIB was associated with earlier intervention, fewer packed red blood cell transfusions, shorter hospital length of stay, and fewer readmissions with GIB. Future research should seek to establish causal relationships between communication practices and outcomes.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the University of Florida Health, Department of Surgery, and Sepsis and Critical Illness Research Center, Gainesville, Florida.

Submitted: August 1, 2016, Revised: August 29, 2016, Accepted: September 2, 2016, Published online: October 25, 2016.

This work will be presented at the 30th Eastern Association for the Surgery of Trauma Annual Scientific Assembly on January 12, 2017 in Hollywood, Florida. This manuscript has never been submitted or published elsewhere.

Address for reprints: Janeen R. Jordan, MD, FACS, University of Florida Health, Gainesville, FL, 1600 SW Archer Rd, Room M-602, Gainesville, FL; email:

© 2017 Lippincott Williams & Wilkins, Inc.