Developing GI bleeding paths requires flexible, complex approach
Allow for complications, and emphasize timeliness of treatment
If you’re developing clinical pathways on gastrointestinal (GI) bleeding, you’ve probably discovered how difficult it can be. Because bleeding can occur along any portion of the GI tract, diagnoses and treatments for various disorders vary widely.
An all-inclusive clinical pathway may be practically impossible, while developing separate pathways for each diagnosis is time-consuming and redundant. No matter which approach you use, make sure length of stay (LOS) takes into account rebleeding and other complications and that procedures such as colonoscopy are carried out in a timely manner.
At Waukesha (WI) Memorial Hospital, clinicians have developed a "generic" clinical path for GI bleeding that can be applied to any GI bleeding problem, says Susan Semrow, RN, BSN, integrated care education coordinator. The path, which they call an "integrated plan of care," was developed in 1995 by a multidisciplinary group of patient-care coordinators, a discharge planner, a dietitian, and physicians.
The group included a five-day LOS in the plan as well as consults, lab tests, patient education, and other factors. (See sample plan, pp. 3-4.) The plan is broad and doesn’t break down GI bleeding into the upper or lower GI tracts, for example.
"I think this was just a way to get us going on how to manage the patients," says Semrow. "There are some aspects of care which may not have been included but may be added as our plan is updated and revised. In the future, we may have to make the plan more specific to the type of [GI] bleeding. We need to review our data to see what specific locations of GI bleeding we are seeing and then determine how to break them out into separate plans, if necessary."
Path eventually will be revised
Other plans of care developed at the hospital have started similarly with a broad path that eventually is revised into more specific paths, she says. The plans are used for a period of time, and the process of care and patient progression are evaluated.
"Data are collected by determining [whether] critical outcomes [were] met or not met, and then used to determine what aspects of the plan may need to be revised," Semrow explains. "That may include breaking the plan out into more specific populations."
With the GI bleeding plan, data analysis has shown that those patients who remain beyond the five-day LOS indicated on the plan had continued bleeding and needed further evaluation.
"Those patients who aren’t discharged after five days have continued to bleed or had other problems, such as neurological problems or weakness [associated] with the bleeding," says Semrow.
There are ways to help reduce LOS, however. For example, on the current path at Waukesha, by day two, patients should receive a GI consult, she says.
"We don’t want to delay patient progression, so we have included as one of our critical outcomes that a GI consult be obtained by day two," Semrow says.
Also on day two, colonoscopy, if necessary, is done.
"That, of course, helps speed things along as well," she adds. "You want to have as much information available as soon as possible to help the patient progress."
Look at upper, lower GI tracts separately
David Puera, MD, professor of medicine and associate chief of gastroenterology and hepatology at the University of Virginia in Charlottesville, says he is not aware of any clinical paths on GI bleeding at his facility. (Puera is a leading authority on Helicobacter pylori, the bacterium that causes peptic ulcers.) But in general, he recommends that clinical paths address the upper and lower GI tracts separately based on whether the patient needs upper or lower endoscopy or X-ray. For the lower GI tract, he says, committees developing paths follow recent guidelines from the American Society of Gastrointestinal Endoscopy in Manchester, MA.1 (See article on guidelines, p. 5.)
One way to improve diagnosis of bleeding of the upper GI tract is by having endoscopy ordered by emergency department (ED) physicians instead of routinely admitting patients suspected of having GI bleeding. That strategy also avoids unnecessary hospitalizations.
"For instance, if there’s a vessel or a clot [noted during endoscopy], those patients should be admitted to the hospital," he notes. "If [physicians] see just a gray base on an ulcer, they could probably make an argument against even admitting the patient."
Should ED physicians order endoscopy?
But Gary Zuckerman, DO, associate professor of medicine at Washington University School of Medicine in St. Louis, disagrees that ED physicians should routinely order or perform endoscopy on patients to see if they need to be admitted.
"It’s very difficult to do that," he says. "If you’ve got a busy [gastroenterology] service, it’s tough to get patients done, and emergency [departments] have problems keeping the patient in the [ED] until the endoscopy team gets assembled to do the procedure. More of our patients [receive endoscopy] in the intensive care unit."
Zuckerman says he and a team of nurses and physicians are developing separate clinical paths for GI bleeding based on three areas of hospitalization, starting with the ED.
"One area is when patients first come into the [ED] and there is a triage decision," he explains. "Does the patient get sent home, or [admitted] to the hospital?"
The second area being considered is when the patient is admitted, and a decision must be made about whether the patient goes to the intensive care unit or to a regular nursing floor. The third aspect of care is related to when the patient who has been sent to the ICU can be discharged to a nursing floor, or when patients admitted to nursing floors can be discharged home. Criteria for those areas depend on the patient’s progress and stability.
"Each of those can be looked at as separate areas," Zuckerman says. "They need to have separate paths."
Keeping LOS down is a challenge, he admits. He recommends that paths include having endoscopy done within at least 72 hours of admission.
"Ideally, it should be done even sooner than that," Zuckerman says. "We like to do them within 24 to 48 hours. There’s evidence that if you look in [to the GI tract] later than 72 hours, then your ability to diagnose where the bleeding was from drops down to closer to what X-ray can tell you. So it’s not very accurate then."
Longer LOS may be necessary
On the other hand, LOS may need to be kept to a minimum of 72 hours in patients with active upper GI bleeding. Zuckerman says that morbidity and mortality related to upper GI rebleeding often occur within the same hospital stay, and that most rebleeding occurs within 72 hours of admission.
"So for patients with active bleeding with those high-risk lesions, they may have to be followed for 72 hours," Zuckerman says.
In addition, he and his colleagues have developed criteria for evaluating patients in the ED for risk of complications.2 Those criteria will be part of the clinical paths for the ED. He says the criteria are called "BLEED," which stands for bleeding that is ongoing, low systolic blood pressure below 100, elevated prothrombin time, erratic mental status, and having a disease that is comorbid and requires admission to the ICU.
"Any one of those criteria, if present, would place the patient at high risk for complications, meaning surgery for GI bleeding, mortality, and rebleeding," Zuckerman says.
References
1. American Society for Gastrointestinal Endoscopy Standards of Training and Practice Committee. The role of endoscopy in the patient with lower gastrointestinal bleeding: Guidelines for clinical application. Manchester, MA; 1996.
2. Kolief MH, Canfield DA, Zuckerman GR. Triage considerations for patients with acute gastrointestinal hemorrhage admitted to a medical intensive care unit. Crit Care Med 1995; 23:1,048-1,054.
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