BLEED - A CLASSIFICATION TOOL TO PREDICT OUTCOMES IN PATIENTS WITH ACUTE UPPER AND LOWER GASTROINTESTINAL HEMORRHAGE

Objective: To develop an outcome prediction tool (BLEED: ongoing bleed ing, low systolic blood pressure, elevated prothrombin time, erratic m ental status, unstable comorbid disease) for clinical use in patients with either acute upper or acute lower gastrointestinal (GI) hemorrhag e. Design: A cohort study. Setting: Barnes Hospital and Jewish Hospita l, two private university-affiliate teaching hospitals in St. Louis, M O. Patients: Four hundred sixty five patients with either acute upper or acute lower GI hemorrhage admitted from the emergency department. I nterventions: Admission of patients to the intensive care unit or hosp ital ward was determined by emergency department physicians, without u se or knowledge of BLEED criteria, Patients meeting any BLEED criteria at their initial assessment in the emergency department were classifi ed as ''high-risk.'' All other patients were classified as ''low-risk. '' Measurements and Main Results: The main outcome measure was the occ urrence of an inhospital complication, defined as recurrent GI hemorrh age, surgery to control the source of hemorrhage, and hospital mortali ty. Patients classified as high-risk had significantly greater rates o f inhospital complications at both Barnes Hospital (relative risk, 2.4 7; 95% confidence interval, 1.38 to 4.44; p < .001) and Jewish Hospita l (relative risk, 8.94; 95% confidence interval, 3.92 to 20.41; p<.001 ) compared with patients classified as low-risk Patients classified as high-risk at either hospital were significantly more likely to develo p additional organ system derangements, require a greater number of tr ansfused units of packed red brood cells, and have longer hospital sta ys compared with patients classified as low risk (p < .006). The BLEED classification also identified a greater frequency of intensive care admission for both low-risk (RR, 4.21; 95% CI, 2.24 to 7.89) and high- risk (relative risk, 1.58; 95% confidence interval, 1.23 to 2.02) pati ents at Barnes Hospital compared with those patients at Jewish Hospita l, although no beneficial effects on patient outcome were reported. Co nclusions: The BLEED classification, applied at initial emergency depa rtment evaluation and before admission, predicts hospital outcomes for patients with acute upper or lower GI hemorrhage. This outcome predic tion tool also identified Variations in intensive care utilization bet ween two hospitals.