title: Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation.
abstract: BACKGROUND
  Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low-risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals.
  
  
  METHODS
  Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper-gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients.
  
  
  RESULTS
  Of 676 people presenting with upper-gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77-0.84]), which in turn was better than the admission Rockall score (0.70 [0.65-0.75]). When introduced into clinical practice, 123 patients (22%) with upper-gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001).
  
  
  CONCLUSIONS
  The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources.
authors.affiliation: Gastrointestinal Units, Glasgow Royal Infirmary, Glasgow, UK.
authors.forename: A J
authors.initials: AJ
authors.lastname: Stanley
authors.forename: D
authors.initials: D
authors.lastname: Ashley
authors.forename: H R
authors.initials: HR
authors.lastname: Dalton
authors.forename: C
authors.initials: C
authors.lastname: Mowat
authors.forename: D R
authors.initials: DR
authors.lastname: Gaya
authors.forename: E
authors.initials: E
authors.lastname: Thompson
authors.forename: U
authors.initials: U
authors.lastname: Warshow
authors.forename: M
authors.initials: M
authors.lastname: Groome
authors.forename: A
authors.initials: A
authors.lastname: Cahill
authors.forename: G
authors.initials: G
authors.lastname: Benson
authors.forename: O
authors.initials: O
authors.lastname: Blatchford
authors.forename: W
authors.initials: W
authors.lastname: Murray
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care; D001803:Blood Transfusion; D005069:Evaluation Studies as Topic; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000145:classification* / Q000503:physiopathology / Q000628:therapy; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment; D012720:Severity of Illness Index