Introduction

Globally healthcare systems and healthcare professionals (HCP) are under increasing pressure, in particular due to the growing shortage of healthcare workers¹. Reducing the intra-hospital patient transportation could potentially free up HCP resources. Intra-hospital transport can further be associated to patient risks due to unexpected events during the transfer² specifically, transportation of clinical ill patients which have been significantly correlated with adverse events³. Additionally, nurses perceive intra-hospital transport as a cause of stress and increased workload.⁴ When transferring critical patients there are several parameters to consider, the electromedical equipment, stability condition and the short time to extract information of the patient to continue with a safe and suitable transfer ⁵. The current study investigates the potential benefits of having single-use therapeutical gastroscopes, needed equipment and utilities available in the intensive care unit (ICU), to treat ICU admitted patients presenting an upper gastrointestinal bleed (UGIB).

Aims & Methods

Between January 2021 and October 2022, an anonymous survey was distributed across 8 countries (Australia, France, Germany, Italy, Spain, United Kingdom, United States of America and Japan). The survey was distributed through M3 Global Research. The main target of the survey were gastroenterologists and gastrointestinal surgeons, from public hospitals, public university hospitals, private hospitals, private clinics, screening centers and ambulatory surgery centers (ASC). Data was collected through Survey Exact and analyzed in Excel.

Results

341 answers from gastrointestinal surgeons and gastroenterologists were collected. 3% of ICU patients present an UGIB during admission. Presently, 45% of patients with UGIB are treated in the ICU, 24% of patients are currently transported to the operating room (OR) and 31% to the endoscopy unit (EU). The average time used transporting patients from the ICU is 21min and 22min to the OR and EU, respectively. 5 to 6 HCP are needed to transport an UGIB patient from ICU to OR/EU. Physicians assumed that 46% CI [42.1;49.9%] of currently transported ICU patients could avoid being transported if single-use therapeutical gastroscopes were available in the ICU and the UGIB management was equally efficient in the ICU as in the OR or EU, meaning 75% of UGIB patients could be managed in the ICU compared to current handling.

Conclusion

The risk and resources associated to intra hospital transport of critical ill patients with UGIB could be reduced in 46% if therapeutical gastroscopes, needed equipment and utilities are available in the ICU. Thereafter, the portability and availability of the single-use therapeutical gastroscope in this scenario, could allow faster attention to the patient in need, free up time, workload and stress of HCP and other staff which are currently involved in the transport and handling of patients with UGIB from ICU.

References

1. Rivlin A, Lumley T. Why is the world now facing a medical recruitment crisis? | World Economic Forum. 2023. Published 2016. Accessed April 27, 2023. https://www.weforum.org/agenda/2023/01/medical-recruitment-crisis-davos23/.
2. Papson JPN, Russell KL, Taylor DMD. Unexpected Events during the Intrahospital Transport of Critically Ill Patients. Acad Emerg Med. 2007;14(6):574-577. doi:10.1197/j.aem.2007.02.034
3. Parmentier-Decrucq E, Poissy J, Favory R, et al. Adverse events during intrahospital transport of critically ill patients: Incidence and risk factors. Ann Intensive Care. 2013;3(1):1-10. doi:10.1186/2110-5820-3-10
4. Song Y, Zhao Q, Yang M, Xie X, Gong M, Chen H. Intrahospital transport of critically ill patients: A cross-sectional survey of Nurses’ attitudes and experiences in adult intensive care units. J Adv Nurs. 2022;78(9):2775-2784. doi:10.1111/JAN.15179
5. Jiménez Herrera MF, Valero Mora E. El traslado interhospitalario de un paciente con hemorragia digestiva por varices esofágicas. Enfermería Clínica. 2011;21(5):284-287. doi:10.1016/J.ENFCLI.2010.12.004

Disclosure

Study started by Ambu. Authors currently working for Ambu.

Introduction

Contemporary data on the outcomes of upper gastrointestinal bleeding (UGIB) in patients with chronic kidney disease (CKD) is lacking.

Aims & Methods

Using international classification of diseases, 10th revision codes, all hospitalisations for UGIB were extracted from the National Inpatient Sample. Admissions were stratified by the presence of CKD. Subanalysis was performed by type of bleeding.

Results

Of the 918,925 UGIB admissions analysed, 239,985 (26.1%) had a medical history of CKD. CKD patients were more likely to be male and less likely to be white compared to patients without CKD. CKD patients had higher crude rates of endoscopy but lower likelihood of undergoing surgery and interventional radiology to control blood loss. On adjusted analysis compared to patients with no CKD, CKD patients had higher odds of all-cause in-hospital mortality (adjusted odds ratio (aOR) 1.34 95% confidence interval (CI) 1.29-1.39). When stratified by bleed type, CKD patients had higher adjusted odds of mortality for both variceal and non-variceal bleeds, compared to patients without CKD.

Conclusion

Patients with CKD admitted with UGIB are more comorbid and are more likely to suffer in-hospital mortality compared to patients without CKD. These differences persisted on-sub-analysis for type of bleed. Knowledge of these trends is important for managing this prevalent patient group.

Introduction

Upper gastrointestinal bleeding (UGIB) is a common medical emergency, particularly in elderly patients, in whom it is often complicated by comorbid conditions and an increased anesthetic risk.

Aims & Methods

The aim of this study was to assess whether emergency endoscopy, although justified by a high Blatchford score, is as relevant in elderly patients as it is in younger patients in terms of therapeutic endoscopic management.
This was a retrospective, monocentric, and analytical study conducted in a tertiary gastroenterology department in North Africa. It included all patients admitted to the emergency department with UGIB between January 2023 and December 2024 who underwent emergency upper gastrointestinal endoscopy.
Inclusion criteria were a Blatchford score strictly greater than 2, according to international recommendations, as well as a history or clinical signs of portal hypertension. Patients were divided into two groups according to age: group 1 (non-elderly, < 65 years) and group 2 (elderly, ≥ 65 years).
Statistical analysis was performed using Jamovi software (version 2.3.28), with comparisons made using the Pearson chi-squared test for qualitative variables. A p-value < 0.05 was considered statistically significant

Results

A total of 155 patients were included, 95 in the non-elderly group and 60 in the elderly group. Elderly patients had significantly more cardiovascular comorbidities. Cardiac disease or arterial hypertension was found in 35% and 33% of elderly patients, respectively, compared with only 5% each in younger patients (p < 0.001). The absence of comorbidities was significantly more frequent in younger patients (18 vs. 3 cases; p = 0.026).
Use of anticoagulant or antiplatelet therapy was also significantly more common in the elderly group (p = 0.0035), with a predominance of aspirin alone or combined with clopidogrel. AODs and VKAs were more frequently used among younger patients. Blood transfusion was required in 47.4% of younger patients and 40% of elderly patients, with no significant difference (p = 0.46).
Endoscopic findings in younger patients most frequently included gastroduodenal ulcers, followed by signs of portal hypertension and esophagitis. Normal endoscopy was observed in 15.8% of younger patients (15 cases) and 26.2% of elderly patients (16 cases), with no statistically significant difference (p = 0.15). In elderly patients, the main diagnoses were ulcers, esophageal varices, esophagitis, and normal FOGD findings.
Therapeutic endoscopic intervention was performed in 39 younger patients (41.1%) versus 15 elderly patients (25%), showing a significant difference (p = 0.0297). This reflects a lower rate of endoscopic hemostasis in the elderly despite identical clinical criteria for emergency indication.

Conclusion

In elderly patients, although emergency endoscopy is indicated based on the same criteria as in younger patients, it less often results in therapeutic intervention. These findings highlight the importance of a personalized approach that accounts for the patient’s overall geriatric profile.

Introduction

Current guidelines provided information on the management of patients with gastrointestinal bleeding, in particular focusing on admission, endoscopic management and medical treatment during the hospital stay. So far, 11-15% of patients treated for GIB required a new hospitalization for a new bleeding episode.

Aims & Methods

The aim of the study is to verify if the management in a dedicated practice after hospital discharge for gastrointestinal bleeding reduces further bleeding and costs. This is an ambispective cohort single center study, including patients observed between May 2022 and September 2023 in our clinical practice dedicated to gastrointestinal bleeding. We enrolled consecutive patients with overt gastrointestinal bleeding or iron deficiency anemia affected by vascular lesions. The effectiveness was defined as a composite endpoint including iron supplementation, blood transfusion, medical treatment and number of hospital stay. Costs were evaluated starting from Diagnosis Related Groups (DRG) codes. The cost effectiveness analysis and ICER has been calculated using the ICERconf.EXE software (Software Prescriptions, c/o Bob Obenchain, California, USA).

Results

In our institute 602 patients with gastrointestinal bleeding were evaluated between May 2022 and September 2023, of these 79 were included in the study. The mean age was 73.8 years (SD±10,8), 46% were female. The source of bleeding was angiodysplasia in 63% of patients, GAVE in 9% (Gastric Antral Vascular Ectasia), erosions in 9%. After the introduction in the dedicated practice, the re-bleeding decrease from 1.3 episodes to 0.2 episodes, p<0.001. The cost average after the practice was 4074 euro (SD ±5485), the average cost before the practice was 4885 euro (SD ±4567), it has been observed a cost saving after the management in the dedicated practice, C diff= -751 euro. The average effectiveness after practice was 8.7 (SD±1.06) and the average effectiveness before the practice was 7.3 (SD ±1.3) with the E diff= 1.47, p<0.001.

Conclusion

The dedicated practice for patients with gastrointestinal bleeding provides effectiveness in reducing transfusion, iron supplementation and hospitalization with a consistent cost reduction.

Introduction

Upper gastrointestinal bleeding (UGIB) is a major cause of mortality in the United States (US). This study aimed to investigate the contemporary trends in the management and outcomes of these patients as well as factors associated with in-hospital mortality, using national data.

Aims & Methods

The US National Inpatient Sample was queried from 2016-2020. Using International Classification of Diseases 10th Revision Codes, all adults >18 admitted with a principal discharge diagnosis of UGIB were extracted along with data about demographics, management and outcomes. Categorical variables were compared using chi-squared and expressed as percentages (%). Logistic regression was performed, adjusting for variables associated with adverse outcomes and reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Data were considered significant if p<0.001.

Results

There were 918,925 hospitalizations for UGIB in the study period. Variceal bleeding occurred in 36,050 (3.9%) of admissions. Endoscopy was performed in 451,450 (49.1%) of admissions, with 10,160 (1.1%) of admissions and 9,355 (1.0%) of admissions requiring interventional radiology and gastrointestinal surgery to control blood loss respectively. The crude rate of all-cause in-hospital mortality was 1.9%. Factors associated with death included variceal bleed (aOR 2.84 CI 2.67-3.02), age (aOR 1.03 CI 1.03-1.03), history of cancer (aOR 2.45 CI 2.35-2.56), ulcer disease (aOR 1.44 CI 1.39-1.49), chronic renal failure (aOR 1.34 CI 1.29-1.37), chronic obstructive pulmonary disease (aOR 1.29 CI 1.24-1.34), receipt of endoscopy (aOR 1.33 CI 1.29-1.38), surgery (aOR 3.92 CI 3.63-4.24) and interventional radiology (aOR 3.33 CI 3.09-3.58).

Conclusion

UGIB remains a significant cause of hospitalisation in the US. Knowledge of the contemporary trends and outcomes of this patient group is important to improve management in this at-risk patient group.

Introduction

Upper gastrointestinal bleeding (UGIB) poses a significant threat in patients presenting to the emergency department, particularly in those with associated hemodynamic instability. Despite major advancements in medical and endoscopic therapeutic options, mortality rates have not shown a substantial decline over the years. This study aimed to assess clinical practice patterns in order to gain a clearer understanding of the pre-endoscopic assessment for patients with acute UGIB.

Aims & Methods

This study was an international online survey based on a prospective two-phase data collection approach, conducted between April 2023 and November 2023. The survey targeted practicing physicians actively involved in managing patients with UGIB. Data collection and management were performed through Research Electronic Data Capture (REDCap), an electronic data collection tool. The survey comprised four key domains: demographics and clinical practice, definitions of hemodynamic instability, pre-endoscopic assessment, and optimal timing of endoscopy, encompassing a total of 33 questions. The primary analysis provided a descriptive assessment of responses reported as proportions. Secondary analyses explored differences in responses based on years of clinical experience, practice setting, and the estimated annual number of UGIB cases encountered

Results

A total of 533 clinicians from 50 countries completed our survey. Among respondents, 54.6% work in university-based hospitals, and 67.7% reported managing over 100 UGIB patients annually. Regarding clinical experience, 55.7% have less than 10 years, with 44.3% with over 10 years of experience. Only 47.1% of respondents reported that their hospitals implement a triage system for UGIB patients. Additionally, 39.6% indicated that they do not use any risk stratification scores at the time of patient presentation. For initial fluid resuscitation, 0.9% saline (40.9%) and balanced crystalloid fluids (39.5%) were almost equally preferred. The rate of fluid resuscitation was reported to depend on the patient’s hemodynamic status by 40.2% of respondents. Most respondents indicated that hemodynamically unstable patients are primarily managed in the emergency department or intensive care unit. A total of 34.3% of respondents indicated that they do not routinely use prokinetics prior to endoscopy in UGIB patients, while 27.6% reported not commonly using them even in cases involving severe bleeding or known gastric emptying disorders. Proton pump inhibitors are administered prior to upper GI endoscopy in all cases by 70.4% of respondents, while vasoconstricting agents are used by 61% in cases of suspected variceal bleeding.

Conclusion

Our survey found considerable variability among respondents regarding the pre-endoscopic management of patients presenting with upper gastrointestinal hemorrhage. The overall adherence to international guidelines was low, which can potentially result in a significant negative impact on patient outcomes.

Introduction

Upper gastrointestinal bleeding (UGIB) continues to pose a significant threat to patients presenting at the emergency department, especially if the patients present with hemodynamic instability. There are still some uncertainties in the guidelines about the stepwise assessment and management for those patients before undergoing endoscopy.

Aims & Methods

Our study aims to report practice patterns to better understand the pre-endoscopic assessment for patients presenting with acute UGIB. This is an international online survey that included a prospective two-phase data collection. The distribution was conducted from April 2023 to November 2023. The target population was active physicians with clinical practices focusing on the management of patients with UGIB. Study data were collected and managed using Research Electronic Data Capture (REDCap), an electronic data collection tool. The survey included four main sections (demographics and clinical practice, definition of hemodynamic instability, pre-endoscopy assessment, and optimal time for endoscopy) with a total of 33 relevant questions. The survey was endorsed by several national and international gastroenterology societies. The primary analysis was a descriptive assessment of individual survey response items in different domains. Descriptive statistics were reported as proportions. Secondary analysis evaluated differences in survey responses according to the years of clinical experience, type of practice location, and the estimated number of UGIB patients presented annually.

Results

In total, 533 clinicians completed our survey from 50 countries. Over half of the respondents work at university-based hospitals (54.6%) and have over 100 UGIB patients hospitalized annually (67.7%). In terms of clinical experience, 55.7% reported less than 10 years and 44.3% with more than 10 years. In 29.1% of the hospitals, there was no specific protocol or guideline for the initial assessment of patients with suspected UGIB, and in 44.7%, there were no emergency on-call interventional radiology services for such cases. Among the respondents, 39.6% do not use any risk stratification scores at the time of patient presentation. Both 0.9% saline (40.9%) and balanced crystalloid fluid (39.5%) were almost equally chosen as initial fluid resuscitation. However, the rate of fluid resuscitation was dependent on the hemodynamic status of 40.2% of the answers. In 40.7% of the answers, clinicians do not use any major hemorrhagic protocol for patients with severe ongoing bleeding and at risk of exsanguination. Prokinetics were generally little or never used prior to endoscopy in patients with UGIB (34.3%) or even in those with known gastric emptying problems (27.6%). The most chosen optimal time for endoscopy was within 24 hours for stable patients with non-variceal bleeding and within 12 hours for variceal bleeding. If patients were unstable but responding to resuscitation, the most chosen time was within 6 hours regardless of the source of bleeding and within 2 hours for those with persistent hemodynamic instability.

Conclusion

Adherence to international gastroenterology guidelines is low. There is a significant variability in different assessment approaches among respondents. Based on our data, the optimal time for endoscopy seems to be dependent on the hemodynamic status of patients with acute UGIB in both variceal and non-variceal bleeding. Our study highlights opportunities for improving consistency in reporting data and identifies potential areas for research.