Mortality Rate in Upper Gastrointestinal Bleeding Associated with Anti-Thrombotic Therapy Before and During Covid-19 Pandemic

Effect of multidisciplinary collaborative emergency intervention using failure mode and effect analysis model on time to bleeding detection, complication rate, and vital signs in upper gastrointestinal hemorrhage patients

BACKGROUND

Upper gastrointestinal hemorrhage (UGH) is a critical condition. Conventional emergency treatment has problems such as delayed detection of bleeding and multiple complications. Multidisciplinary collaborative emergency intervention based on the failure mode and effect analysis (FMEA) model may optimize the treatment process, so as to improve clinical outcomes.

AIM

To investigate the effect of multidisciplinary collaborative emergency intervention based on FMEA model on the time to bleeding detection, incidence of complications, and vital signs in patients with UGH.

METHODS

A total of 101 UGH patients treated in our hospital from September 2021 to September 2023 were selected and categorized into a control group (n = 50) and an observation group (n = 51) according to the order of filing. Conventional emergency treatment or conventional emergency treatment + multidisciplinary collaborative emergency intervention based on the FMEA model was given. The effective rate of hemostasis, treatment status, occurrence of complications, and the degree of nursing satisfaction in the two groups were statistically analyzed, as well as the scores of vital signs [systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and blood oxygen saturation (SpO₂)], and negative emotions [Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD)] before and after intervention.

RESULTS

The effective rate of hemostasis in the observation group was 96.08%, higher than that of the control group (82.00%; P < 0.05). In the observation group, the time to discover continued bleeding or rebleeding and the length of hospital stay were shorter than those of the control group, and the number of bleeding episodes, blood transfusion, and hospitalization expenses were less than those of the control group (P < 0.05). After intervention, SBP, DBP, and HR in the observation group were lower than those of the control group, and SpO₂ was higher than that of the control group (P < 0.05). HAMA and HAMD scores in the observation group were lower than those of the control group after intervention (P < 0.05). The incidence of complications in the observation group was 3.92%, which was lower than that of the control group (18.00%; P < 0.05), and the degree of nursing satisfaction was 94.12%, higher than that of the control group (80.00%; P < 0.05).

CONCLUSION

The application of multidisciplinary collaborative emergency intervention based on the FMEA model to UGH patients can improve the effect of nursing intervention, assist in rapid clinical hemostasis, and shorten the time to detect continued bleeding or rebleeding. It can also adjust the mental state of patients, restore stable vital signs, and have positive significance in reducing complications and improving the degree of nursing satisfaction among patients.

Effect of multidisciplinary collaborative emergency intervention using failure mode and effect analysis model on time to bleeding detection, complication rate, and vital signs in upper gastrointestinal hemorrhage patients

BACKGROUND

Upper gastrointestinal hemorrhage (UGH) is a critical condition. Conventional emergency treatment has problems such as delayed detection of bleeding and multiple complications. Multidisciplinary collaborative emergency intervention based on the failure mode and effect analysis (FMEA) model may optimize the treatment process, so as to improve clinical outcomes.

AIM

To investigate the effect of multidisciplinary collaborative emergency intervention based on FMEA model on the time to bleeding detection, incidence of complications, and vital signs in patients with UGH.

METHODS

A total of 101 UGH patients treated in our hospital from September 2021 to September 2023 were selected and categorized into a control group (n = 50) and an observation group (n = 51) according to the order of filing. Conventional emergency treatment or conventional emergency treatment + multidisciplinary collaborative emergency intervention based on the FMEA model was given. The effective rate of hemostasis, treatment status, occurrence of complications, and the degree of nursing satisfaction in the two groups were statistically analyzed, as well as the scores of vital signs [systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and blood oxygen saturation (SpO₂)], and negative emotions [Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD)] before and after intervention.

RESULTS

The effective rate of hemostasis in the observation group was 96.08%, higher than that of the control group (82.00%; P < 0.05). In the observation group, the time to discover continued bleeding or rebleeding and the length of hospital stay were shorter than those of the control group, and the number of bleeding episodes, blood transfusion, and hospitalization expenses were less than those of the control group (P < 0.05). After intervention, SBP, DBP, and HR in the observation group were lower than those of the control group, and SpO₂ was higher than that of the control group (P < 0.05). HAMA and HAMD scores in the observation group were lower than those of the control group after intervention (P < 0.05). The incidence of complications in the observation group was 3.92%, which was lower than that of the control group (18.00%; P < 0.05), and the degree of nursing satisfaction was 94.12%, higher than that of the control group (80.00%; P < 0.05).

CONCLUSION

The application of multidisciplinary collaborative emergency intervention based on the FMEA model to UGH patients can improve the effect of nursing intervention, assist in rapid clinical hemostasis, and shorten the time to detect continued bleeding or rebleeding. It can also adjust the mental state of patients, restore stable vital signs, and have positive significance in reducing complications and improving the degree of nursing satisfaction among patients.

Trends for Admission, Mortality and Emergency Surgery in Upper Gastrointestinal Bleeding: A Study of Eight Years of Admissions in a Tertiary Care Hospital

Introduction

Most studies have shown a declining incidence of upper gastrointestinal bleeding (UGIB) in recent years. Data regarding mortality were controversial; in non-variceal bleeding, the increasing age of the population, increased use of anti-thrombotic and anticoagulant therapy in patients with cardiovascular diseases, and the use of non-steroidal anti-inflammatory drugs are counterbalanced by the progress in endoscopic therapy with stable mortality.

Material and Method

We performed a retrospective, cross-sectional study that included patients admitted with UGIB in Clinical Emergency Hospital Craiova during 2013-2020.

Results

3571 patients with UGIB were selected; a trend toward increased admission for UGIB from 2013 to 2019 was noted, with a significant decrease in 2020. Non-variceal bleeding remains the most frequent form, with a slight increase in variceal bleeding, of Mallory-Weiss syndrome and angiodysplasia, and a 3-fold decrease for unknown etiology bleeding (with no endoscopy performed) during the 2017-2020 period as compared to 2013-2016. There was a trend toward decreased mortality, with lower mortality in 2017-2020 (12.83%) compared to 2013-2016 (17.41%). The mortality for variceal bleeding and peptic ulcer bleeding has declined, but mortality for non-variceal bleeding has slightly increased during 2013-2020. Mortality has decreased in admissions during regular hours/after hours and weekdays/weekends, but the difference (off-hours and weekend effects) had increased. The percentage of endoscopies performed in the first 24 hours after admission and the rate of therapeutic endoscopy increased during 2017-2020; the median time between admission and endoscopy was 17.0 hours during 2017-2020 and 59.1 hours during 2013-2016. The proportion of patients who needed emergency surgery for uncontrolled bleeding has significantly declined since 2013-2015, with an average value of 1% in the last 5 years of the study.

Conclusion

Increased admissions for UGIB, with lower mortality, especially for peptic ulcer bleeding and variceal bleeding were noted; higher percentages of therapeutic endoscopies and endoscopies performed during the first 24 hours after admission were also recorded.

Improved outcomes in patients with non-variceal upper gastrointestinal bleeding while undergoing antithrombotic therapy: A propensity score matching analysis

BACKGROUND

This study sought to examine the effect of antithrombotic use on clinical outcomes in non-variceal upper gastrointestinal bleeding (UGIB).

METHODS

Patients consecutively diagnosed with non-variceal UGIB between February 2019 and September 2020 were divided into two groups based on their antithrombotic use: users and non-users. Using propensity score matching (PSM) and multivariable regression analyses, the impact of antithrombotic use prior to UGIB presentation on clinical outcomes was examined.

RESULTS

In the entire cohort, there were 210 and 260 patients in the antithrombotic user and non-user groups, respectively. Using PSM analysis with seven covariates, two matched groups of 157 patients were created at a 1:1 ratio. In the matched cohort, despite their longer hospital stays and a higher rate of intensive care unit admissions, the patients in the user group had lower 30- and 90-day mortality rates (4.5% vs. 14.0 %; p = 0.003 and 8.9% vs. 18.5 %; p = 0.014, respectively). In the entire cohort, multivariable analyses adjusted for confounding factors revealed that antithrombotic use was associated with lower risks of in-hospital (adjusted OR: 0.437; 95 % CI: 0.191-0.999), 30-day (adjusted OR: 0.261; 95 % CI: 0.099-0.689), and 90-day (adjusted OR: 0.386; 95 % CI: 0.182-0.821) mortality.

CONCLUSION

Antithrombotic use prior to UGIB presentation was found to be an independent protective factor for all-cause mortality.

The Reduction of After-Hours and Weekend Effects in Upper Gastro-intestinal Bleeding Mortality During the COVID-19 Pandemic Compared to the Pre-Pandemic Period

BACKGROUND

In upper gastrointestinal bleeding (UGIB), admissions after normal working hours and during weekends may be associated with increased mortality.

AIM

To assess the evolution of the after-hours and weekend effects during the COVID-19 pandemic as a result of progressive improved management despite management challenges during the pandemic.

METHODS

We performed an observational study of patients admitted for UGIB at a tertiary academic center between March 2020 and December 2021, compared to the corresponding timeframe before the pandemic. Admissions were assessed based on regular hours versus after-hours and weekdays versus weekends. We stratified patients based on demographic data, etiology, prognostic scores, the time between symptom onset and admission, as and between admission and endoscopy. The outcomes included mortality, rebleeding rate, the requirement for surgery and transfusion, and hospitalization days.

RESULTS

802 cases were recorded during the pandemic, and 1006 cases before the pandemic. The overall mortality rate was 12.33%. Patients admitted after hours and during weekends had a higher mortality rate compared to those admitted during regular hours and weekdays (15.18% versus 10.22%, and 15.25% versus 11.16%), especially in cases of non-variceal bleeding. However, the difference in mortality rates was reduced by 2/3 during the pandemic, despite the challenges posed by COVID-19 infection. This suggests that there was an equalization effect of care in UGIB, regardless of the admission time. The differences observed in mortality rates for after-hours and weekend admissions seem to be primarily related to a higher proportion of patients who did not undergo endoscopy, while the proportion of severe cases remained similar. Blood requirements, hospital days, and rebleeding rate were similar between the two groups.

CONCLUSION

Admissions during weekends and after-hours have been associated with increased mortality, particularly in cases of non-variceal bleeding. However, the impact of this association was significantly reduced during the pandemic.

The Prevalence of Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review and Meta-Analysis

Introduction: Severe acute respiratory syndrome coronavirus 2 caused the coronavirus disease of 2019 (COVID-19), which rapidly became a pandemic, claiming millions of lives. Apart from the main manifestations of this infection concerning the respiratory tract, such as pneumonia, there are also many manifestations from the gastrointestinal tract. Of these, bleeding from the gastrointestinal tract is a significant complication quite dangerous for life. This bleeding is divided into upper and lower, and the primary pathophysiological mechanism is the entering of the virus into the host cells through the Angiotensin-converting enzyme 2 receptors. Also, other comorbidities and the medication of corticosteroids and anticoagulants are considered to favor the occurrence of gastrointestinal bleeding (GIB). Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the studies were searched in two different databases (Scopus and PubMed) from November 2019 until February 2023. All studies that reported GIB events among COVID-19 patients were included. Results: 33 studies were selected and reviewed to estimate the prevalence of GIB. A total of 134,905 patients with COVID-19 were included in these studies, and there were 1458 episodes of GIB. The prevalence of GIB, in these 33 studies, ranges from 0.47% to 19%. This range of prevalence is justified by the characteristics of the COVID-19 patients. These characteristics are the severity of COVID-19, anticoagulant and other drug treatments, the selection of only patients with gastrointestinal manifestations, etc. The pooled prevalence of gastrointestinal bleeding was estimated to be 3.05%, rising to 6.2% when only anticoagulant patients were included. Conclusions: GIB in COVID-19 patients is not a rare finding, and its appropriate and immediate treatment is necessary as it can be life-threatening. The most common clinical findings are melena and hematemesis, which characterize upper GIB. Treatment can be conservative; however, endoscopic management of bleeding with embolization is deemed necessary in some cases.

The Prevalence of Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review and Meta-Analysis

Introduction: Severe acute respiratory syndrome coronavirus 2 caused the coronavirus disease of 2019 (COVID-19), which rapidly became a pandemic, claiming millions of lives. Apart from the main manifestations of this infection concerning the respiratory tract, such as pneumonia, there are also many manifestations from the gastrointestinal tract. Of these, bleeding from the gastrointestinal tract is a significant complication quite dangerous for life. This bleeding is divided into upper and lower, and the primary pathophysiological mechanism is the entering of the virus into the host cells through the Angiotensin-converting enzyme 2 receptors. Also, other comorbidities and the medication of corticosteroids and anticoagulants are considered to favor the occurrence of gastrointestinal bleeding (GIB). Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the studies were searched in two different databases (Scopus and PubMed) from November 2019 until February 2023. All studies that reported GIB events among COVID-19 patients were included. Results: 33 studies were selected and reviewed to estimate the prevalence of GIB. A total of 134,905 patients with COVID-19 were included in these studies, and there were 1458 episodes of GIB. The prevalence of GIB, in these 33 studies, ranges from 0.47% to 19%. This range of prevalence is justified by the characteristics of the COVID-19 patients. These characteristics are the severity of COVID-19, anticoagulant and other drug treatments, the selection of only patients with gastrointestinal manifestations, etc. The pooled prevalence of gastrointestinal bleeding was estimated to be 3.05%, rising to 6.2% when only anticoagulant patients were included. Conclusions: GIB in COVID-19 patients is not a rare finding, and its appropriate and immediate treatment is necessary as it can be life-threatening. The most common clinical findings are melena and hematemesis, which characterize upper GIB. Treatment can be conservative; however, endoscopic management of bleeding with embolization is deemed necessary in some cases.