Background: Hospital readmissions within 30 days of discharge are a marker of the quality of care and reflect the effectiveness of the discharge process. ED visits are also a marker of hospital-based acute care following discharge, but little is known about the role of the ED during the post-discharge period.
Study design: Prospective study.
Setting: Acute-care hospitals in California, Florida, and Nebraska.
Synopsis: Using the Healthcare Cost and Utilization Project state inpatient and ED databases, all discharges between July 1, 2008, and Sept. 31, 2009, were evaluated for residents aged 18 years or older from three hospitals in three states. After exclusions, 5 million index hospitalizations among 4 million unique patients were studied.
Approximately 40% of the more than 1 million post-discharge acute-care encounters involved a visit to the ED.
Limitations of this study include that the data was derived from only three states, and only hospital-based acute-care visits were measured (i.e. visits to physician offices were not included). As hospitalists, we are responsible for discharges and care transitions. Being sensitive to the common medical conditions resulting in post-discharge ED encounters might improve care transitions.
Bottom line: Hospital readmission rates underestimate ED use following discharge.
Citation: Vashi AA, Fox JP, Carr BG, et al. Use of hospital-based acute care among patients recently discharged from the hospital. JAMA. 2013;309(4):364-371.
Restrictive Transfusion Strategy Beneficial in Upper GI Bleeding
Clinical question: What is the hemoglobin threshold for transfusion of red cells in patients with acute upper GI bleeding?
Background: Controlled trials have shown that restrictive transfusion strategies (Hgb<7) are as effective as liberal transfusion strategies (Hgb<9) in critically ill patients. These studies have excluded patients with GI bleeding. In cases for which GI is not severe, the safest transfusion strategy is controversial.
Study design: Single-center study at Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
Synopsis: A total of 921 adult patients with acute upper GI bleeding were enrolled and assigned: 461 to a restrictive transfusion strategy (hemoglobin<7) and 460 to a liberal strategy (hemoglobin<9). Patients with massive exsanguinating bleeding, acute coronary syndrome, peripheral vasculopathy, stroke, transient ischemic attack, lower GI bleed, recent trauma or surgery, or low risk of rebleeding were excluded. The primary outcome measure was the rate of death from any cause within the first 45 days.
Secondary outcomes included the rate of further bleeding and the rate of in-hospital complications.
Statistically significant benefit in following a restrictive versus liberal strategy was demonstrated in all major outcomes: mortality (5% vs, 9%, P=0.02), rate of further bleeding (10% vs 18%, P=0.01), and rate of complications (40% vs. 48%, P=0.02).
The study is limited by its inability to be generalized to all patients with acute GI bleeding, as patients with massive exsanguinating bleeds and those with low risk of rebleeding were excluded.
Bottom line: Restrictive transfusion (Hgb<7) significantly improved outcomes for patients with acute upper GI bleeding.
Citation: Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11-21.
Need for Non-ICU Acid Suppression Might Be Predictable
Clinical question: What are the risk factors for nosocomial bleeding in non-critically-ill patients?
Background: Acid-suppressive medication has been shown to reduce the incidence of nosocomial GI bleed in the ICU, but current guidelines recommend against its use in non-critically-ill patients. However, a subgroup of these patients might possess a high enough risk for GI bleed that prophylaxis is warranted.