Introduction: Upper gastrointestinal bleeding (UGIB) is a common Emergency Department (ED) presentation. Early endoscopic intervention, supported by Glasgow Blatchford Score (GBS) severity, has been shown to reduce re-bleeding rates and lower morbidity and mortality. However, emergent endoscopy is not necessary for all patients. Low-risk patients can be managed with outpatient follow-up. Other important management decisions such as blood transfusion (Hb <70) and use of proton pump inhibitors (PPI) also warrant evaluation. The aim of this study was to compare the timing and appropriateness of endoscopy and blood transfusion and proton pump inhibitor (PPI) use in a tertiary care setting to the standard of care. Methods: A retrospective cohort study was conducted to examine the management of patients presenting with UGIB to the ED in 2016 using a standard chart review methodology. TANDEM and EDIS (Emergency Department Information System) databases were queried to identify patients using specified ICD 10 codes and the CEDIS (Canadian Emergency Department Information System) presenting complaints of vomiting blood or blood in stool/melena. Outcome measures included: patient characteristics, the GBS to determine appropriateness of endoscopic intervention, diagnoses, blood transfusion indications and utilization of oral or intravenous PPIs. Data were entered into a REDCap database and analyzed using standard non-parametric statistical tests. Results: A total of 200 patients, 59% male (118/200), mean age 59 years (range 18 - 92 years) were included. The median GBS was 9. 79% of patients (157/200) underwent endoscopy during the hospital visit: 30% of patients with GBS 0-3 (13/43) and 80% patients with GBS 4 (125/157) underwent endoscopy 24 hours. The two most common endoscopic diagnoses were peptic ulcers (39%, 61/157) and varices (18%, 28/157), while 14% (22/157) had a normal diagnosis or mild gastritis. 174/200 patients (87%) were given IV or oral PPI in the ED whereas the remaining 26 (13%) did not receive PPI in hospital. 46% of patients (89/194) received blood transfusion, but only 51% (45/89) were administered based on the 70 g/L threshold while in 40% (36/89) of patients the less restrictive threshold of 90 g/L was used. Conclusion: A majority of UGIB patients presenting to a tertiary hospital ED appropriately received endoscopy 24 hours based on a GBS score 4. PPI use was appropriate but a proportion of patients received inappropriate blood transfusions.