Examination of Patient Transfer Criteria to Higher Medical Institutions After Emergency Endoscopy at a Private Medical Facility Without Hospital Beds

Background: Because the clinical course of gastrointestinal bleeding varies, urgent judgments regarding the severity of a patient’s condition, indications for endoscopic hemostasis, and transfer to a higher medical institution are needed at private medical facilities without hospital beds. The present study aimed to evaluate the characteristics of patients with vital sign uctuations during emergency endoscopy for gastrointestinal bleeding and experiencing rebleeding within 30 days after initial endoscopy. We then investigated criteria for transferring patients to higher medical institutions based on the results. Methods: We retrospectively evaluated the characteristics of 91 patients who underwent emergency endoscopy for gastrointestinal bleeding at our facility without hospital beds between January 2016 and September 2020. The patients were divided into 2 groups: 13 with vital sign uctuations during emergency endoscopy and/or rebleeding within 30 days after an initial endoscopy as the required transfer group and 78 without either as the nonrequired transfer group. Results: No signicant differences in age, sex, location, or endoscopic treatment were observed between the 2 groups. However, the prevalence of comorbidities was signicantly higher in the required transfer group (P <0.001). Moreover, multivariate logistic regression analysis identied comorbidities (odds ratio [OR], 10.646; 95% condence interval [CI], 2.868–68.330; P = 0.001) as an independent risk factor for vital sign uctuation and/or rebleeding. Conclusions: These ndings suggest that comorbidity presence is a poor prognostic factor in patients with gastrointestinal bleeding, for whom transfer to higher medical institutions needs to be actively considered. bleeding is associated with VSF during emergency endoscopy and/or rebleeding within 30 days of the rst endoscopy and might be a factor inuencing poor prognosis. VSF be an absolute indicator for transfer to higher medical institutions after emergency endoscopy in a private facility without beds. Overall, patients with comorbidities are at risk of signicant VSF and rebleeding and should be actively considered for transfer after emergency endoscopy.


Background
With the aging of the Japanese population, the rate of gastrointestinal (GI) bleeding as a background for the administration of antithrombotic medication and nonsteroidal anti-in ammatory drugs (NSAIDs) has increased [1,2]. In countries or regions where the population is aging, such as in Japan, many patients are middle-aged or elderly and/or have comorbidities, and the number of these patients is expected to increase in the future. As the clinical course of GI bleeding varies, urgent judgments regarding the severity of a patient's condition, indications for endoscopic hemostasis, and transfer to a higher medical institution are required at private medical facilities without hospital beds. In the present study, we retrospectively evaluated the characteristics of patients who underwent emergency endoscopy for GI bleeding to clarify appropriate criteria for transferring patients to higher medical institutions.

Study design and patient selection
We performed a retrospective analysis of the characteristics of 91 patients for whom upper and lower GI bleeding was suspected and emergency endoscopy was performed between January 2016 and September 2020 at our private medical facility without hospital beds. Each patient was 18 years or older and underwent emergency endoscopy to con rm recent onset of GI bleeding. The following clinical and endoscopic data for patients with GI bleeding were collected for all 91 patients: age, sex, comorbidities, location, endoscopic treatment, and antithrombotic medication, including antiplatelet medication and anticoagulant medication. We designated patients with vital sign uctuation (VSF) during emergency endoscopy and/or rebleeding after initial endoscopy as candidates for transfer. Rebleeding was de ned as recurrent hematemesis, hematochezia and melena observed within 30 days after initial endoscopy and demonstrated by a second endoscopy. VSF was de ned as one of the following: (1) systolic blood pressure <90 mmHg or a decrease of 30 mmHg or more from normal systolic blood pressure, (2) heart rate >100 beats/minute, and (3) respiratory rate >22 breaths/minute. Ninety-one patients were divided into 2 groups: required transfer (reqTr), a group of patients with VSF during emergency endoscopy and/or rebleeding; and nonreqTr, a group of patients without VSF.
Statistical analysis SPSS for Windows software (SPSS Japan, Tokyo, Japan) was used for statistical analyses. We performed an unpaired t-test for comparisons between two groups for continuous variables, Fisher's exact test for comparisons between two groups for categorical variables, and a logistic regression analysis to identify risk factors for anomalous vital signs. P values <0.05 were considered to be signi cant.

Ethics
The present study was approved by the Onaka Clinic Ethics Committee (OCIRB-2021-001) on October 24th, 2020.
Lower GI bleeding (LGIB) accounted for approximately 70% of cases. Examination of patient transfer criteria to higher medical institutions We examined criteria for patient transfer to higher medical institutions. Using our database, we identi ed 13 candidates who met the transfer criteria. Table 2 shows a comparison of the characteristics between the reqTr and nonreqTr groups. Although no signi cant differences in age, sex, location, endoscopic treatment, or antithrombotic medication were observed between the two groups, the proportion of patients with comorbidities was signi cantly higher in the reqTr group than in the nonreqTr group (84.6% vs. 28.2%; P <0.001).  Considering the above results, the clinical features of 5 cases of rebleeding were examined in detail ( Table 4). The average age of the 3 male and 2 female patients with rebleeding was 69.6 years; upper GI rebleeding occurred in 3 patients, and lower GI rebleeding occurred in 2. There were 4 cases with comorbidities, and 2 of them were not transferred at the discretion of the endoscopist because VSF did not occur during or after endoscopy. All patients with upper GI bleeding had an ulcer with an exposed blood vessel, and clipping hemostasis was performed as the initial treatment at our private facility. In the two cases of anastomotic ulcers, blood transfusion and additional endoscopic treatment were required because bleeding was not suppressed, even after transfer. Two cases of lower GI bleeding involved advanced rectal cancer and diverticular bleeding. The patient with rectal cancer had severe anemia (Hb 5.7 g/dl) and decreased blood pressure, and it was di cult to conservatively stop bleeding; therefore, this patient required transfusion and surgery after transfer. In the diverticular bleeding case, anticoagulant and antiplatelet drugs were used in combination for hypertension, atrial brillation, and ischemic heart disease, and the bleeding point was not identi ed by initial endoscopy, resulting in conservative treatment. Rebleeding occurred 2 days later; exposed blood vessels were con rmed in a large diverticulum, and the bleeding was stopped by directly grasping at the base of the diverticulum.

Discussion
In this study, VSF during emergency endoscopy and rebleeding within 30 days after rst endoscopy were de ned as indicators for transfer to higher medical institutions. Hence, the presence of comorbidities extracted as the independent risk factor for these indicators may be important for rapid triage of patients requiring transfer. Most patients with VSF or rebleeding have peptic ulcers, diverticular bleeding, and ischemic enteritis with comorbidities, possibly because they have more severe hemorrhage, resulting in lower systolic and diastolic blood pressure, tachycardia, and increased respiratory rate. When faced with VSF and uncontrollable bleeding despite appropriate hemostatic treatments during emergency endoscopy, it is critically important to both understand and stabilize the patient's general conditions and to make a clinical decision regarding transfer of urgent patients to higher medical institutions. Many studies have examined the severity of upper and lower gastrointestinal bleeding and predictive tools for proper acute triage settings. The Glasgow-Blatchford Score (GBS), which is designed to predict the need for a blood transfusion, intervention to control bleeding, rebleeding, or death, and AIMS65, which aims to predict all-cause mortality, are scoring systems for treatment and emergency transfer priorities for patients with upper GI bleeding [3,4]. The cohort study by Horibe et al. [5] advocates the Horibe gAstRointestinal BleedING scoRe (HARBINGER), a score of 3 variables (1 point each for absence of daily proton pump inhibitor use in the week before the index presentation, shock index [heart rate/systolic blood pressure ≥1], and blood urea nitrogen/creatinine ≥30) that is superior to the GBS and AIMS65 in terms of simplicity and accuracy as a triage tool to identify patients with upper GI bleeding who require hospitalization and emergency endoscopy. Patients with a HARBINGER ≥1 are identi ed as candidates for hospitalization. In our study, it was found that all cases of upper GI bleeding with VSF during emergency endoscopy corresponded to the shock index (heart rate/systolic blood pressure ≥1), suggesting that the decision to set VSF as a criterion for transferring to higher medical institutions was valid. Rebleeding acts as a sign of instability, and emergency transfer should be considered for patients with high-risk upper GI bleeding. The location on the lesser curvature of the stomach or on the posterior or superior wall of the duodenum, size over 2 cm in diameter, and presence of high-risk lesions (spurting, oozing blood, nonbleeding visible vessel, and an adherent clot) have been reported as endoscopic predictors of increased risk of GI rebleeding [6].
On the other hand, clinical predictors of GI rebleeding include comorbidity, anemia (low hemoglobin levels), need for transfusion, nding of fresh red blood during a rectal examination or during nasogastric suction or vomiting, melena, advanced age (older than Page 7/9 With regard to LGIB, Strate et al. [7] reported the following seven clinical risk factors associated with severe LGIB (de ned as continuous and/or recurrent bleeding): tachycardia, low systolic blood pressure, syncope, nontender abdominal examination, bleeding per rectum within the rst 4 h of medical assessment, use of aspirin, and more than two active comorbidities. Patients with 3 or more of these risk factors are at a high risk of severe bleeding. Furthermore, Aoki et al.
[8] described a predictive model of severe LGIB (NOBLADS score), i.e., NSAID use, no diarrhea, no abdominal tenderness, systolic blood pressure ≤ 100 mmHg, albumin level < 3.0 g/dL nonaspirin antiplatelet drug use, Charlson comorbidity index score ≥ 2, and syncope. These studies suggest that hemodynamic instability and comorbidities are important factors associated with the severity and rebleeding of upper and lower GI bleeding. Moreover, in lower GI bleeding, the use of antithrombotic medication is associated with increased severity. Chong et al. [9] reported that patients taking aspirin were 2.6 times more likely to develop severe lower GI bleeding. Many private facilities, such as ours, do not have an on-site laboratory and cannot perform blood tests on the same day. Thus, it is necessary to triage patients who need urgent hospitalization with the minimum necessary information. In private facilities, extracting low-risk patients from among those with GI bleeding may prevent unnecessary transfers, reduce medical costs, and e ciently utilize medical resources.
The present study had several limitations. This was a single-center retrospective study with a small number of cases. In addition, well-known rebleeding risk factors may have been taken into consideration when deciding whether to transfer patients after endoscopy. Moreover, as our facility is a private clinic, the number of critically severe cases was small, and options for endoscopic treatment were limited. We will continue to accumulate cases and strive to establish optimal transfer standards for emergency patients with GI bleeding who are at high risk of sudden changes in their physical condition.

Conclusions
The presence of comorbidities with upper and lower gastrointestinal bleeding is associated with VSF during emergency endoscopy and/or rebleeding within 30 days of the rst endoscopy and might be a factor in uencing poor prognosis. VSF be an absolute indicator for transfer to higher medical institutions after emergency endoscopy in a private facility without beds. Overall, patients with comorbidities are at risk of signi cant VSF and rebleeding and should be actively considered for transfer after emergency endoscopy.