Gastrointestinal Hemorrhage

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1 Gastrointestinal Hemorrhage Quality Measures Length of Stay RCC Costs per Case Mortality Rate Eligible Readmission Within 30 Days. Critical Event(s) Evaluation Phase/Acute Phase Baseline pain assessment Documentation of screening for pneumococcal/influence (seasonal) vaccine VTE/(DVT) risk assessment Appropriate VTE/(DVT) prophylaxis if applicable CBC, platelets, complete metabolic profile ECG PT/ PTT/ INR, Type and screen Endoscopy completed expeditiously if clinically warranted & appropriate Orthostatic vital signs as clinically appropriate Medication reconciliation addressed Progressive Phase Smoking cessation advice/counseling if indicated Administration of pneumococcal/influenza (seasonal) vaccine if eligible Colonoscopy completed if ordered Discharge Phase Assess understanding of discharge instructions Medication reconciliation addressed

2 GI Hemorrhage Guideline Assessment & Consultation Complete Day 1 Comprehensive history and physical P Baseline skin assessment and documentation of present on admission P,N Baseline pain assessment** P,N VTE(DVT) risk assessment ** P,N Glasgow-Blatchford risk assessment tool as an aide to guide initial site of treatment P Evaluation of current medication for sources of GI bleed including NSAID, anticoagulants, herbal supplements, etc. P,N Orthostatic vital signs as clinically appropriate** N Education Complete Day 1 Assess barriers to learning P,N Orientation to environment, safety protocols N Infection control procedures/ protocols P,N Medication teaching as appropriate N Tests Complete Day 1 CBC, Platelets, Complete Metabolic Profile** ECG**, U/A CXR PT/ PTT/ INR ** Type and Screen,** Type and Cross if indicated Endoscopy completed expeditiously if clinically warranted & appropriate** Treatments Complete Day 1 Cardiac monitor as needed Diagnostic NGT insertion as indicated Based on bleeding source, consider bowel prep Transfuse as ordered IV /Tubes/Drains IV / IV access Evaluation / Acute Phase (1 Day) Admission assessment including smoking history N Initiate plan of care P,N Fall / Risk assessment P,N MRSA/VRE screen if indicated N Consider surgical consult if indicated P GI consult ordered P Documentation of screening for pneumococcal / influenza (seasonal) vaccine** N Explain all tests, procedures, plan of care and expected length of stay P,N Assess knowledge regarding procedures and plan of care P,N Consider bleeding scan or UGI if endoscopy contraindicated Gastrin Level if indicated Guiaic stool X1 as indicated Avoid routine second look endoscopic therapy Medications Complete Day 1 Medication Reconciliation addressed** P,N Medications as ordered. Proton Pump Inhibitor (use caution in patients with renal disease) Appropriate VTE(DVT) prophylaxis if applicable** Diet & Elimination Activity Avoid NSAID Diet As Ordered - Advance As Tolerated P,N,D Intake & Output if indicated N Monitor and document bowel and bladder elimination N N, T-p Ambulate as tolerated Discharge Planning / Pyschosocial Assess support network N,CM,SW Initiate discharge plan including appropriate referrals N,CM,SW Consider discharge based on endoscopy result P Discharge notification P,N,CM,SW Patient Outcomes Safety maintained Advancing diet Assessments completed Patient stabilized Acceptable patient comfort level Pt &/or family aware of plan of care Bleeding source identified ** critical event P = LIP D = Dietician (nutrition) T-s = Speech/Swallow Therapist N = Registered Nurse CM = Case Manager T-r = Respiratory Therapist Ph = Pharmacist SW = Social Worker T-p = Physical Therapist

3 GI Hemorrhage Guideline Assessment & Consultation Progressive Phase Reassessment of response to treatment and patient care P,N Monitor effects of medication and assess for adverse drug reactions P,N Pain management P,N Nutritional consult if ordered D Education Tests Treatments Patient and family education of discharge plan, signs and symptoms of GI bleed as it relates to medications, diagnosis, activity, changes in lifestyle, and signs and symptoms requiring medical intervention P,N,D,T-p,Ph Reinforce anticipated length of stay and discharge plan P N,T-r, SW Smoking cessation advice/counseling if indicated** Reassess need for serial lab work H & H as indicated PT, PTT, INR as indicated Screen for H pylori Colonoscopy completed if ordered** Consider D\C cardiac monitoring IV /Tubes/Drains Medications Diet & Elimination Activity Discharge Planning / Psychosocial Patient Outcomes IV access Consider conversion of IV meds to PO meds Administration of pneumococcal/influenza(seasonal) vaccine if eligible** N Evaluate for stool softener/laxative Proton Pump Inhibitor (use caution in patients with renal disease) Diet as ordered - Advance as tolerated P,N,D Intake & Output if indicated N Monitor and document bowel and bladder elimination N Ambulate as tolerated N,T-p Promote independence with ADL's N N, CM,SW Reassess discharge planning needs Discharge notification P,N,CM,SW Consider discharge based on Endoscopy/colonoscopy results if appropriate P Safety maintained Ambulating/Performing ADL's w/optimal independence Acceptable patient comfort level Bleeding source identified ** critical event P = LIP D = Dietician (nutrition) N = Registered nurse CM = Case Manager Ph = Pharmacist SW = Social Worker T-r = Respiratory Therapist T-p = Physical Therapist

4 GI Hemorrhage Guideline Assessment & Consultation Education Discharge Phase Reassessment of response to treatment and patient care P,N Monitor effects of medication and assess for adverse drug reactions P,N Pain management P,N Assess patient and family understanding of discharge instructions including diagnosis, activity, medications, pain management, diet, smoking cessation, signs & symptoms requiring intervention, and follow up medical appointment** P,N,D,Ph,T-p,SW (use teach back method) Tests Treatments IV /Tubes/Drains D/C IV access Medications Medication reconciliation addressed** P,N Discharge with a prescription for PPI or H2 receptor antagonists for peptic ulcers Diet & Elimination Activity Discharge Planning / Psychosocial Patient Outcomes Diet as ordered P,N,D Ambulate as tolerated N,T-p Discharge plan confirmed N,CM, SW Hemodynamic stability Stable and safe appropriate discharge Patient/family demonstrates understanding of discharge instructions ** critical event P = LIP D = Dietician (nutrition) N = Registered nurse CM = Case Manager Ph = Pharmacist SW = Social Worker T-r = Respiratory Therapist T-p = Physical Therapist

5 Admission risk marker Glasgow-Blatchford Score Score component value Blood Urea 6 5 < < < Hemoglobin (g/l) for men 12.0 < < < Hemoglobin (g/l) for women 10.0 < < Systolic blood pressure (mm Hg) <90 3 Other markers Pulse 100 (per min) 1 Presentation with melaena 1 Presentation with syncope 2 Hepatic disease 2 Cardiac failure 2 In the validation group, scores of 6 or more were associated with a greater than 50% risk of needing an intervention. Score is equal to "0" if the following are all present: 1. Hemoglobin level >12.9 g/dl (men) or >11.9 g/dl (women) 2. Systolic blood pressure >109 mm Hg 3. Pulse <100/minute 4. Blood urea nitrogen level <18.2 mg/dl 5. No melena or syncope 6. No past or present liver disease or heart failure In a study published in Lancet on January 3, 2009, 16% of patients presenting with UGIB had GBS score of "0", considered low. Among these patients there were no deaths or interventions needed and the patients were able to be effectively treated in an outpatient setting

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7 References GI Hemorrhage Barkun, A., Bardou, M., Marshall, J., (2003). "Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding". American College of Physicians.November 18, 2003; 139: Barkun, A., Kuipers, E., Sung, J., et al. (2010). "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding". Annals of Internal Medicine. January 19, 2010;152: Chen, I., Hung, M., Chiu, T., et al. (2007). "Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding". American Journal of Emergency Medicine. (2007) 25, Cerulli, M., Iqbal, S. (2009). Upper gastrointestinal bleeding. emedicine from Web MD, Retrieved February 3, 2010, from 5 Milliman Care Guidelines Inpatient And Surgical Care 14Th Edition National Guideline Clearinghouse. (2008). Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Retrieved February 19, 2010, from Scottish Intercollegiate Guidelines Network. (2008). Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Elliott House. Retrieved February 19, 2010, from Stanley, A., Ashley,D., Dalton, H., Mowat, C., Gaya, D., Thompson, E., et al.(2009).outpatient management of patients with low-risk upper-gastrointestinal hemorrhage: multicentre validation and prospective evaluation. The Lancet.373 (9657) Vreeburg EM, Terwee CB, Snel P, et al. (1999). "Validation of the Rockall risk scoring system in upper gastrointestinal bleeding". Gut 44 (3): PMID Uptodate. (2009, September 30). Approach to the adult patient with upper gastrointestinal bleeding.retrieved March 1, 2010, from Uptodate. (2009, September 30). Approach to the adult patient with lower gastrointestinal bleeding.retrieved March 1, 2010, from This Clinical Guideline has been developed with support from your institution as a member of Long Island Health Network. It is strongly recommended for the treatment of patients with this diagnosis. It does not take into account unusual patient needs which may dictate different plans of care.

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