| | Comments are from: Margaret Freundl, MSN, RN, CS, Director, Disease Management St. John Health System, in Warren Michigan. St. John Health System is an 8 hospital health care system which developed an inpatient clinical guideline for acute GIB this spring. The key recommendations, clinical algorithm, standing orders and pathway along with patient education material is included below. We had great debate working on this project (which I had thought would be relatively simple!). Here are some issues that surfaced: 1. Whether or not to include both upper and lower GIB. We concluded to do both, since so many cases begin in ED and often it is not clear where the bleed is at that point. We acknowledged some differences in LOS with upper vs lower, mostly due to the LGI prep time. 2. Gastroenterologists are not the only endoscopists at several of our hospitals...there are surgeons who also do the EGDs, etc, and they get very offensive if not included up front. On the back side, they often don't do the interventional procedures so if there is a positive finding the cases may get delayed. We are going to track that as part of our outcomes measurement. 3. Know the population being admitted for GIB at your site. At one of our hospitals a few years back, when we first worked on this, the impression was we were going to see a lot of ETOH-type cases. After we audited, we discovered that MANY of our cases were elderly using NSAIDS (hence, the pt ed material). This has been reinforced in a recent study this year re: ulcer management (?Kaiser study)...they found more cases were getting screened/treated for Hpylori but there was no change in patient education practices. 4. Our target is getting timely GI workup done (1 day for upper, 2 days for lower because of prep) and to encourage discharge on day of procedure for those with negative findings...for those with interventional procedures, they must be kept in hospital for another 48-72h per the literature because of risk of re-bleed. What we found on baseline audits was that most of the cases not discharged were being treated like "high risk" cases, but had negative findings...this will entail more than a clinical pathway to fix. We proposed that the endoscopist contact the attending from GI Lab to notify them of negative findings and "sign off" on the case....we are also going to be monitoring this as I think it will be a tough change. If the endoscopist doesn't do this, then I think the problem is going to fall in the lap of the case manager.
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Contributed By: Margaret Freundl, MSN, RN, CS |
