Introduction: Acute upper gastrointestinal bleeding (UGIB) is a common presentation to emergency departments (ED). Of these patients, 35-45% receive a blood transfusion. Guidelines for blood transfusion in UGIB have been well established, and recommend a hemoglobin (Hb) level below 70 g/L as the transfusion target in a stable patient. There is no consensus on a transfusion threshold for unstable UGIB. There is limited data regarding physician practices in the ED. The aim of our study is to determine the appropriateness, by expert consensus, of blood transfusions in UGIB in a tertiary care hospital ED. Methods: We retrospectively reviewed patients presenting with UGIB to the University of Alberta Hospital ED in 2016. These patients were then screened for blood transfusions. Data were obtained from the patient records. Chart derived data were verified with records obtained from the blood bank. For each patient, the history, vitals, Glasgow Blatchford Score (GBS), relevant labs, and record of blood transfusions were collected and organized into a case summary. Each patient summary was presented individually to a panel of three expert clinicians (2 Gastroenterology, 1 Emergency Medicine), who then decided on the appropriateness of each blood transfusion by consensus. Results: Blood transfusions (data available 395/400) were given to 51% (202/395) of patients presenting with UGIB. Of these, 86% (174/202) were judged to be appropriate. Of the 395 patients, 34% (135/395) had a Hb of <70 g/L. Of these, 93% (126/135) were transfused, and all of these were considered appropriate. 18% (70/395) had a Hb between 71-80. 74% (52/70) of these patients were given blood, and 79% (41/52) were considered appropriate. 13% (50/395) of the patients had a Hb between 81-90, with 28% (14/50) receiving a transfusion. Of these, 36% (5/14) were deemed to be appropriate. 35% (140/395) of patients had a Hb of >90. 7% (10/140) of these received blood. 20% (2/10) were considered appropriate. Conclusion: The panel of expert clinicians judged 86% of the blood transfusions to be appropriate. All transfusions under the recommended guideline of 70 g/L were considered appropriate. In addition, the majority of transfusions above a Hb of 70 g/L were considered appropriate, but 37% were not. Further studies evaluating the feasibility of current guideline recommendations in an ED setting are required. Educational interventions should be created to reduce inappropriate blood transfusions above a Hb 70 g/L.

Introduction: Upper gastrointestinal bleeding (UGIB) is a common medical condition presenting to emergency departments (ED) and associated with substantial morbidity, mortality, and healthcare expenditures. Our aim was to evaluate the incidence of patients presenting to ED with UGIB in a large population-based surveillance cohort. Methods: The National Ambulatory Care Reporting System (NACRS) was used to identify all presentations to emergency departments for UGIB in Alberta from fiscal year 2010 to 2015 (n=56519) using the International Classification of Diseases Codes (ICD-10) in any diagnostic position. Baseline characteristics and UGIB incidence were calculated using descriptive statistics. Joinpoint regression models were used to calculate the average annual percent change (AAPC) with 95% confidence intervals (CI). Results: The median age of 56519 UGIB presentations was 56 years (interquartile range: 41 to 74 years), 56% were male, and 245% had at least one comorbidity. At time of disposition from the ED , 48.3% were admitted to or transferred to another hospital, 51.4% discharged, and 0.3% died in the emergency department. Further, 10.8% underwent upper endoscopy during their admission to the emergency department. The annual incidence of UGIB were 230.6 (2010), 232.8 (2011), 241.0 (2012), 242.2 (2013), 244.6 (2014), and 242.2 (2015) per 100,000 person-years. Between 2010 and 2015 the incidence of UGIB presenting to ED significantly increased overtime (AAPC=1.1; 95% CI: 0.3 to 2.0). Conclusion: UGIB is a common presentation to emergency departments and has been increasing overtime. Future studies are necessary to evaluate the underlying cause of UGIB and to determine its burden to Albertas healthcare system.

Introduction: Patients with upper gastrointestinal bleeding (UGIB) are at risk for serious adverse events (SAE) after emergency department (ED) discharge. Endoscopy can aid in risk stratification but is not easily available. Therefore, stratifying using pre-endoscopic risk scores can aid ED physicians in disposition decisions. The aim of this study was to conduct a systematic review to assess the predictive value of pre-endoscopic risk scores for risk-stratification of ED UGIB patients. Methods: We searched 4 databases from inception to March 2015 with search terms related to “UGIB” and “ED”. Inclusion criteria were: 1) adult UGIB patients presenting to the ED; 2) risk scores without endoscopic predictors developed and validated in variceal and non-variceal UGIB patients. We excluded case reports, reviews, abstracts, animal studies and commentaries. In 2 phases (screening and full-review), 2 reviewers independently screened articles for inclusion. SAE included 30-day death, recurrent bleeding and need for intervention. Two reviewers independently extracted patient level data and the consensus data was used for analysis. We report kappa for the article selection, and pooled sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratios and accuracy with 95% CI for the risk scores. Results: We identified 3,173 articles, of which 3,065 were excluded in phase I (kappa 0.88, 95% CI 0.83-0.93). In phase II, we included 16 of the 108 remaining articles (kappa 0.84, 95% CI 0.70-0.97); 3 studied Glasgow Blatchford Score (GBS), 1 clinical Rockall score (cRockall) and 2 AIMS65; 6 compared GBS and cRockall, 3 compared GBS, a modification of the GBS and cRockall and 1 compared the GBS and AIMS65. Overall, the accuracy of the GBS, cRockall and AIMS65 was 0.47 (95% CI 0.46-0.47), 0.47 (95% CI 0.46-0.49) and 0.62 (95% CI 0.61-0.62), respectively. The accuracy for the GBS with a cut-off score of 2 was 0.73 (95% CI 0.71-0.74). Conclusion: None of the risk scores identified by our systematic review were robust and hence, cannot be recommended for use in clinical practice. However, the GBS with a cut-off score of 2 was superior over other risk scores. Future prospective studies are needed to develop robust new scores for use in ED patients with UGIB.

Introduction: Acute upper gastrointestinal bleeding is a potentially life-threatening medical emergency that frequently requires red blood cell (RBC) transfusions. However, the optimal hemoglobin thresholds for transfusion is controversial. The objective of this study was to establish the most efficacious transfusion threshold. Methods: A systematic review of the published literature was completed. MEDLINE, Health technology assessment database, Cochrane central register, Cochrane database of systematic reviews, and EMBASE were searched from inception to May 2015 using search terms including “blood transfusions”, “hemoglobin”, and “red blood cell”. Studies were included if they: reported original data, were peer-reviewed, studied adult populations, were randomized controlled clinical trials and primarily focused on clinical efficacy or effectiveness of liberal and restrictive pre-transfusion hemoglobin level thresholds. Quality was assessed using the Cochrane Risk of Bias tool. Data were extracted and meta-analysis was conducted using a random effects model to determine the risk ratio for: all-cause mortality, further bleeding and any adverse events. All steps were completed independently by two reviewers. Results: The literature search identified 4037 unique abstracts. Of these, 156 abstracts proceeded to full text review. 154 articles were excluded during full-text review resulting in 2 articles for final analysis. The total number of participants included was 701. The hemoglobin threshold to transfuse RBC varied between 70-80g/L versus 90-100g/L in restrictive and liberal policies, respectively. Both studies were at low risk of bias. Meta-analysis resulted in a pooled decreased risk of all-cause mortality (RR 0.65, 95% CI 0.44-0.96), re-bleeding (RR 0.63, 95% CI 0.46-0.85) and adverse events (RR 0.83, 95% CI 0.73-0.95) in the restrictive blood transfusion group versus the liberal blood transfusion group. Conclusion: While the evidence is limited, the risk of death is lower and there is no significant harm for a restrictive strategy. In this context, there is a decreased risk of transfusion associated adverse events among those receiving a restrictive strategy and should be considered for its impact on patient safety and health system resources.