Utility of routine admission chest radiographs in patients with acute gastrointestinal hemorrhage admitted to an intensive care unit

Gastrointestinal bleeding

Gastrointestinal bleeding is a common complaint encountered in the emergency department and frequent cause of hospitalization. Important diagnostic factors that increase morbidity and mortality include advanced age, serious comorbid conditions, hemodynamic instability, esophageal varices, significant hematemesis or melena, and marked anemia. Because gastrointestinal bleeding carries a 10% overall mortality rate, emergency physicians must perform timely diagnosis, aggressive resuscitation, risk stratification, and early consultation for these patients.

Introducing a clinical pathway for acute peptic ulcer bleeding in general internal medicine wards

OBJECTIVE

Management of acute peptic ulcer bleeding (PUB) is expensive and there is little evidence to prove the cost-effectiveness of a clinical pathway. The purpose of this study was to introduce a clinical pathway in hospitalized patients with acute PUB to evaluate its impact on costs and other outcomes.

MATERIAL AND METHODS

The clinical pathway was designed for and implemented in hospitalized patients, and a physicians reminder system that included chief residents, checklists, and case review meetings was also utilized. Use of medicine for acid suppression, length of hospital stay (LOS), and treatment costs were compared between patients before and after implementation of the clinical pathway. Outcome measures included the rate of recurrent bleeding, rate of repeat upper gastrointestinal (UGI) endoscopy, and rate of readmission within 30 days of discharge.

RESULTS

This clinical pathway significantly reduced the use of intravenous medicine for acid suppression from 88% to 34%, with mean LOS down from 6.7 to 3.6 days, mean cost of medications decreased from New Taiwan Dollars (NTD) 8768 to NTD 3940 (cost down 55.1%), mean cost of diagnostic tests lowered from NTD 12,560 to NTD 9493 (cost down 24.4%), and mean total hospital cost down from NTD 33,142 to NTD 19,519 (cost down 41.1%). Outcome measures were not significantly different.

CONCLUSIONS

Introduction of a clinical pathway is an effective method for reducing costs while maintaining quality of care in the management of PUB.

Implementing a guideline for the request of chest and abdominal x-rays in nontrauma pathologic conditions in an ED

OBJECTIVE

The purpose of this study is to evaluate the impact of implementing a guideline for the request of chest and abdominal x-ray to reduce unnecessary examinations in nontraumatic pathologic conditions.

METHODS

We selected most common chief complaints in nontrauma pathologic conditions at emergency department (ED) and reviewed the available literature to determine the effectiveness of chest and abdominal x-rays for each one. We developed a guideline for the request of x-rays according to the chief complaints, including modulating factors derived from initial clinical evaluation. Guideline implementation was achieved through a multifaceted educational intervention. To evaluate its impact, both in the absolute number and in the adequateness of x-ray requests, we compared data obtained from patients coming to the ED at 2 different time points, October 2004 (preimplementation) and October 2005 (postimplementation).

RESULTS

In the preimplementation period, 52.7% of the patients underwent chest x-rays and 28.0% abdominal x-rays, whereas in the postimplementation period, the proportions decreased to 41.8% and 13.5%, respectively (P<.001 in both cases). The adequateness of x-ray requests improved, as shown by a reduction in the number of inappropriate x-ray examinations (absolute error reduction of 9.2%; 95% confidence interval, 7.7-10.8, and relative error reduction of 59.8%; 95% confidence interval, 49.7-69.8).

CONCLUSIONS

In our ED, implementing a specifically designed guideline for the request of chest and abdominal x-ray examinations in nontraumatic pathologic conditions reduced the absolute number of requests and the rate of inappropriate requests.

Ineffectiveness of routine abdominal radiography in patients with gastrointestinal hemorrhage admitted to an intensive care unit

GOALS

To determine the utility of plain abdominal radiography in the initial evaluation of acute gastrointestinal (GI) hemorrhage in a medical intensive care unit.

BACKGROUND

Plain abdominal radiographs are frequently used in the routine evaluation of patients with GI bleeding. The utility of these studies in the intensive care unit setting is unclear.

STUDY

The study was a retrospective chart review of 71 adult subjects admitted to a medical intensive care unit with the diagnosis of GI bleeding. Subjects were excluded if they presented with peritoneal signs, received an abdominal CT scan in the 24 hours prior to admission, or were chronically treated with immunosuppressive medication. Subjects were divided into two cohorts based on whether or not they underwent plain abdominal radiography during the first hospital day. The primary study endpoints were hospital mortality, intensive care unit length of stay, and whether or not radiographic findings altered clinical management.

RESULTS

Of the 71 patients admitted with a diagnosis of GI bleeding (mean age 65.8 +/- 14.5 years, 73.2% male), 56 (79%) had a plain abdominal radiograph performed. Subjects who had a plain film did not differ significantly from those who did not in age, gender, degree of anemia, degree of coagulopathy, or in severity of illness as measured by Acute Physiology and Chronic Health Evaluation (APACHE II) score. There was no statistically significant difference in hospital mortality or intensive care unit length of stay between patients who received plain films and those who did not. In no subject (0%; 95% confidence interval, 0%-5.4%) did abdominal radiography reveal an abnormality that altered clinical management.

CONCLUSIONS

Based on our observations, plain films of the abdomen do not appear to alter clinical outcomes or management decisions for patients with GI bleeding and normal abdominal examinations who are admitted to the intensive care unit.

Routine Chest Radiography in a Primary Care Setting

PURPOSE

To determine the frequency, diagnostic yield, outcomes, cost, and rate of false-positive results of routine chest radiography performed in asymptomatic patients in the primary care setting.

MATERIALS AND METHODS

Radiography reports on all patients who underwent routine or screening posteroanterior and lateral chest radiography at a university-affiliated primary care clinic in 2001 were reviewed. Radiographic results were coded as normal or minor findings or as major abnormalities, such as pulmonary nodules, requiring further diagnostic evaluation. Outcomes of patients with major abnormalities were established by using chart reviews or reviewing additional radiographs. Costs were estimated by using 2002 Medicare reimbursement rates. The main measures assessed were frequency, costs, and rate of false-positive results of routine chest radiography.

RESULTS

Of 3812 radiographs obtained at the primary care clinic, 1282 (34%) were ordered for routine or screening purposes by the referring physician. Nine hundred twenty-two radiographs were obtained in male patients and 360 were obtained in female patients; their mean and median age was 49 years (age range, 4-87 years). Fifteen chest radiographs showed major abnormalities. No patient younger than 40 years had a major abnormality. Fourteen of the 15 findings of major abnormalities proved to be false-positive. No disease requiring treatment was diagnosed as a result of radiographic findings. The total cost for follow-up radiography and computed tomography was US dollar 46,609.49.

CONCLUSION

Routine chest radiography has low diagnostic yield in asymptomatic primary care patients.

Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding

OBJECTIVES

Acute nonvariceal upper gastrointestinal (GI) bleeding is the most common medical emergency encountered by gastroenterologists resulting in high patient morbidity and cost. We sought to establish if a GI bleeding clinical care pathway could improve the quality and cost effectiveness of inpatient medical care.

METHODS

A disease management program for acute upper GI bleeding was established. Length of stay, time to endoscopy, utilization of potentially unnecessary radiological tests, acid suppression, and cost of care were compared between patients pre- and postinitiation of GI bleeding pathway guidelines.

RESULTS

The instituted GI bleeding management program significantly reduced the use of intravenous H2-blockade from 65.3% to 47.7% (p = 0.002). The use of radiological tests, time to endoscopy, and length of hospital of stay were unchanged. There was a trend toward a reduction in total cost and variable direct cost per patient admitted with acute upper GI bleeding, from $5,381 to $4,627 and from $2,269 to $1,952, respectively.

CONCLUSION

A clinical care pathway may affect the management of acute upper GI bleeding and reduce costs. However, there are significant limitations and barriers to the overall effectiveness of such a pathway in actual clinical practice.