The Oakland Score to identify low risk patients with lower GI bleed that can be safely discharged

The Oakland score was derived in 2015 but it somehow slipped my attention. The score is quite simple and mostly includes at a combination of age, vital signs and hemoglobin level to risk stratify patients [Oakland score MdCalc link]. 

This new external validation study was a multicenter effort that was conducted in 140 US hospitals. It identified 38,067 patients admitted to the hospital with a primary diagnosis of lower GI bleed by ICD-10 codes. They retrospectively applied the Oakland score to these inpatients to see if this decision instrument could identify a group that was safe for discharge. Test characteristics of the score were reported at several cut-offs (8,9, and 10 points)

The primary outcome to determine “safe discharge” was a composite of an absence of the following: in hospital rebleeding, RBC transfusion, therapeutic colonoscopy, mesenteric embolization, laparotomy, in hospital death and readmission with subsequent lower GI bleeding 28 days.

Results?

Average age was 70 years old and 68% of patients received a blood transfusion. Yikes! These were not low risk patients… probably why they were admitted in the first place.

Applying the rule to this inpatient cohort identified a measly 8.7% of patients considered safe for discharge at the 8-point threshold with a sensitivity of 98.4% and 16% specificity. If the threshold score was increased to 10, identified 17.8% with similar sensitivity but increased specificity to 32%.

Overall, it’s a pretty bad decision instrument in this population as it is not discriminatory. It pretty much calls everyone positive. 

However, I think there is a bigger issue with this study.

It was conducted on inpatients. The decision to admit was already made!

For overall utility, it should have been done in the ED. Nevertheless, the authors did state, “a prospective cohort study is needed, in which all patients presenting to the emergency department are included, regardless of their admission status.”

For what it is worth, I might see myself documenting a low-risk Oakland score to support my decision to send home a low-risk patient with lower GI bleed home. But in its current form, I fear the lack of specificity may result in more patients being admitted to hospital if we apply it without thinking.

Ultimately, yes, I would really like to see this study prospectively validated in an ED population and compared to gestalt. Anyone interested in a research project?

Covering:

Oakland K, Kothiwale S, Forehand T, Jackson E, Bucknall C, Sey MSL, Singh S, Jairath V, Perlin J. External Validation of the Oakland Score to Assess Safe Hospital Discharge Among Adult Patients With Acute Lower Gastrointestinal Bleeding in the US. JAMA Netw Open. 2020 Jul 1;3(7):e209630. doi: 10.1001/jamanetworkopen.2020.9630. PMID: 32633766; PMCID: PMC7341175. [link to full text article]