Effect of Implementing Nursing Protocol on clinical Outcomes of Acute Non-variceal Upper Gastrointestinal Bleeding Patients

Background : One of the most common reasons for hospitalization, morbidity, and mortality related to digestive illnesses is Non-variceal upper GIT bleeding. Despite the improvement in the field, management of patients with Non-variceal Upper Gastrointestinal Bleeding (NVUGIB) has


Introduction:
Acute non-variceal upper gastrointestinal bleeding remains a frequent and difficult emergency for gastroenterologists and general doctors (1) .Acute upper gastrointestinal bleeding (AUGIB) is a common, expensive, and possibly lethal illness that calls for quick evaluation and aggressive medical treatment.AUGIB is defined as haemorrhage that begins close to the ligament of Treitz in order to distinguish it from lower gastrointestinal bleeding involving the colon and middle gastrointestinal bleeding involving the small intestine distal to the ligament of Treitz (2) .Non-variceal bleeding is more frequent than variceal bleeding and peptic ulcer disease which accounts for 50-70%.Incidence of variceal bleeding accounts for less than 10% of all causes of GI bleeding but has a high mortality rate of about 30% during their initial hospitalization (3) .Various studies from Southeast Asia and Nepal have reported variable rates of bleeding from stomach and variceal ulcers.Depending on the various socioeconomic and demographic traits of the local people in these areas, the findings will vary (4) .Non-variceal causes of acute upper gastrointestinal bleeding including gastric and duodenal peptic ulcer common causes of UGI bleeding.The rate of bleeding peptic ulcers caused by the use of aspirin and non-steroidal anti-inflammatory drugs has increased, despite the extensive use of proton pump inhibitors to reduce the incidence of UGI bleeding in the last 15 years.Furthermore, the mortality rate hasn't changed much over the last 20 years, primarily due to population aging and the presence of comorbidities (5) .Symptoms of AUGIB include melena, hematemesis, and anaemia.Hematemesis is the vomiting of bright red blood or "coffee ground" material.Other symptoms include breathlessness, syncope, and epigastric pain (because of volume reduction).When the source of the gastrointestinal blood loss is unknown, bleeding may be difficult to detect.When a patient has AUGIB, some prognostic factors may increase the chance of complications, such as morbidity and mortality.If any one or more of the prognosis indicators listed below are true, the patient should be admitted to the intensive care unit: age over 60, shock, comorbid conditions (such as heart, kidney, and liver disorders), Endoscopic endoscopy revealed substantial bleeding symptoms, persistent bleeding, low systolic blood pressure, and the need for more than six units of blood (6) .A lot of risk factors are known to influence the outcome in UGIB as Age, comorbidities, presence of shock, endoscopic diagnosis, hemoglobin values at the time, stigmata of recent hemorrhage and need for a blood transfusion have all been described as significant risk factors for re-bleeding and death (7) .The management of acute UGIB has significantly improved since the development of emergency endoscopy and contemporary endoscopic techniques for hemostasis control.Bleeding stops spontaneously without the need for any intervention in most of the patients admitted to the hospital, except necessitating just hemodynamic assistance.However, up to 20% of patients require extra intervention because they continue to bleed or rebleed.Re-bleeding more frequently has consistently been cited as the biggest risk factor for death and has an impact on how UGIB patients fare (8) .Several experimental scoring methods have been developed to support expecting result in patients with an assessment to improving patient management and supporting costeffective use of resources (9) .The Rockall score is the most extensively used risk scoring system in UGIB.It was created in 1996 following the analysis of data from a significant English audit.The score, which takes into account the patient's age, hemodynamics, comorbidities, and endoscopic findings, was created to evaluate the risk of death after presentation with UGIB.The clinical Rockall score, which only takes into account clinical variables, is used to identify patients with AUGIB who encounter a bad result, such as mortality or recurrent bleeding.Which AUGIB patients died or had recurrent bleeding is also determined using the entire Rockall score, which takes into account clinical and endoscopic variables (9) .A nurse's involvement in treating a patient with upper GI haemorrhage calls for particular consideration.The nurse must first play a specialized role in providing nursing care to a patient who is in hypovolemic shock; patient comfort can also be preserved by determining whether analgesia is necessary.The nurse will be expected to provide continual assessments for the patient's fluid and electrolyte status and should feel comfortable performing ABC (airway, breathing, and circulation) resuscitation (10) .Nurses are in the key position to carry out health care.Health care providers who have continuous contact with patients and their families and have the opportunities to assess potential problem, specific care for patient and give teaching about all aspects of care (11)   .
Nurses are in the key position to carry out health care.Health care providers who have continuous contact with patients and their families and have the opportunities to assess potential problem, specific care for patient and give teaching about all aspects of care (11)   .Significance of the study: Acute upper gastrointestinal (UGI) bleeding represent an incidence of 100.000 population/ year, and it represents a one of most common cause of hospital admission with a markedly associated morbidity and mortality rate, especially in elderly subjects (5) .In Egypt, there are roughly 100 cases of upper gastrointestinal bleeding per 100,000 people per year.About four times as many people experience gastrointestinal bleeding from the upper GI tract as from the lower GI tract (12) .Based on the statistical data of the Gastroenterology Intensive care unit Sohag University hospital at 2021, number of patients admitted with 400 patients per year (13) .Re-bleeding and death risk assessment using Rockall risk score: it is evaluating the system in patients with non-variceal UGIB; the score ranged from 0-9 and were divided into three risk categories; l risk 3revealed the good performance index of RS system in UGIB patient's triage.

Method
The study was conducted throughout three main phases which are preparatory phase, implementation phase and evaluation phase.Preparatory phase:-An approval from the ethical committee was taken from the Dean of the Faculty of Nursing, South valley University to conduct the study and delivered to the hospital authorities at Sohag University Hospital and approval to gather the necessary data after clarify the purpose and nature of the study before data collection.Informed agreement was obtained from the chief of the gastroenterology intensive care unit at Sohag University Hospital.The researcher created the instruments utilized in this study after reviewing the pertinent literature.The tools of the study were tested for content validity by five experts (3) in the field of critical care nursing specialists, (1) Gastroenterologist, and (1) medical biostatistics to ensure validity.

Ethical considerations
The nature and aim of the study was clarified to each patient and to his relatives in case of unconscious patients.Patients were given the assurance that the research's data would not be used again without their consent.Patients were assured privacy and anonymity.The researcher emphasized that the participation will be voluntary to participate in the study and the patients were given the assurance that they might reject to participate in the trial at any moment and/or withdraw without giving a reason.

Discussion
Acute upper gastrointestinal bleeding (AUGIB) is common, costly, and potentially life-threatening medical emergency and requires prompt assessment and aggressive medical management (17) .UGIB is a frequent medical emergency and a significant contributor to morbidity and mortality.Non-variceal UGIB is primarily brought on by peptic ulcer bleeding.The main risk factors for UGIB include the use of non-steroidal anti-inflammatory medicines (NSAIDs), low-dose aspirin use, and Helicobacter pylori infections (1)   .Regarding the socio-demographic characteristics of patients involved in this study, In relation to age the mean age in study group was (45.50±3.72)and for the control group was (44.76±2.88).This finding comes in line with Mohamed.A.S, et al. 2020 (11) who study Clinical Results for Patients with Haematemesis in the Intensive Care Unit at Alrajhy Liver Hospital and the Impact of Nursing Guidelines and reported that mean age in study group was (46.54±4.72)and for the control group was (43.76±2.98).Concerning gender, the results of the current investigation showed that most of studied patients in research and routine groups were male (55% & 60 % respectively), which supported by a study done by Junaid Khan, 2018 (18) who reported that the mean age of the patients was 43.3 ± 13.80.80 (53.3%) of the patients were male and 70 (46.7%)were females.From the researcher point of opinion, this finding is related to the great rate of exposure to occupational stressors for males than females, in addition to incidence of smoking is higher in males, which is supported by Marti-Aguado, D., et al. 2022 (19) who study Cigarette smoking and liver diseases and address that Cross-sectional and retrospective studies have found increasing evidence that smoking cigarettes slows the development of chronic viral hepatitis.The underlying mechanisms are complex and involve numerous pathophysiological pathways.However, research looking into the development of fibrosis does not always reflect on smoking status.Concerning comparison between control and study group in relation to causes of acute non-visceral upper gastrointestinal bleeding based on endoscopic findings and presence of past medical history, the current results revealed that most common cause of NVUGIB in both study and control group was peptic ulcer (37.5 % & 32.5 % respectively) with no significant difference.This is similar to results of Kawaguchi, K., et al. 2017 (1) , who study management for non-variceal upper gastrointestinal bleeding in elderly patients, and reported that in his cohort study Gastric ulcers were the most frequent with 206 cases (41%) of UGIT bleeding.In addition, the present study illustrate that nearby half of patients in the research group and half of subjects in routine group were had Past family history of GIT disease (45 % & 50% respectively), and the second common comorbidity was hypertension (17.5% & 22.5% respectively) in both groups.Which come in agreement with study prepared through (11) , who results showed that about third of studied patients in both groups had Previous family history of hepatic disease (36% & 40% respectively) with no difference, while come in contrast with (10) who study the Clinical Outcomes and Patient Satisfaction Assessment among Upper Gastrointestinal Bleeding at Qena University Hospital at Upper Egypt, and revealed that the highest percentage of studied patients in study group (66.6%) had past medical history of diabetes mellitus and in the control group (40.7%) had diabetes mellitus, followed by history of chronic liver diseases which represent (26% & 40.7% respectively) in both groups.Regarding comparison between control and study group in regards to hemodynamic and arterial Blood gases parameters monitoring, the present study indicated that no statistical significant difference was founded among both group subjects in the day of ICU admission but a significant difference was observed in the 3 rd day of stay, from the researcher point of view it is related to the application of nursing protocol of care for subjects group with acute Nonvariceal upper gastrointestinal bleeding that promote and provide suitable supportive management.This results supported with study prepared by Shebl, A.M., et al, 2013 (20) who reported the study group saw an increase in systolic blood pressure of more than 100 mmHg and a normalized pulse rate after the administration of nursing intervention when compared to the routine group, when studying clinical outcomes and patient satisfaction as a result of nursing intervention between UGITB .Moreover it was contrasting to research done by Mohamed, A.S, et al. 2020 (11) who reported that no statistical significant difference was founded among both studied subjects in the day of ICU admission in all parameters, and also on 3 rd day except for temperature and mean arterial blood gases.Considering comparison of Glasgow coma scores among studied subjects, the current results demonstrate significant increase in GCS score in study group at the 3 rd day with significant difference between both study and control group ( p value <0.001).This agrees with findings of research prepared by Shebl, A.M., et al, 2013 (20) who indicate that the majority of the study group's patients were awake, which following the use of nursing intervention, In relation to Rockall score for study and control group, the current results exposed that half of studied subjects were at high score for mortality with no statistical significant difference on 1 st day of admission, while on 3 rd day more than half of research group subjects were at low risk comparing to control group were near half of patients were at moderate risk with statistical significant difference with (p value 0.046).Regarding length of ICU stay, the recent study revealed that mean length of stay for research group was (3.08±0.27)and for control group was (4.34±0.55)with statistical significant difference (p value < 0.001), which comes in agreement with study prepared by Mohamed, A.S, et al. 2020 (11) who reported that mean length of ICU stay was (3.08±0.27and 4.34±0.55)with p-value (0.004).And in relation to mortality rate the study showed that the rate was higher in control group than study group this can be explained from the researchers points of view that the application of nursing care protocol help to improve patients general condition, hemodynamic, conscious statue that subsequently decrease mortality rate in study group than control group who exposed to routine hospital care.This agree with Skok & Sinkovic, 2011 (21) who found that the average length of stay was (2.8+1.9), and in consistent with Frank, A 2014 (22) , who mentions that the average duration of stay for the 240 patients who were the subject of the study was (12.5 ± 5.2) days.

Conclusion:
Based on the results of the current research it has been demonstrated that implementation of nursing care protocol for patients with acute nonvariceal upper gastrointestinal bleeding improves patients' clinical outcomes and decrease rate of complication occurrence

Recommendations:
Based on the results findings it recommended that: Provide the gastroenterology intensive care units with clear, illustrative nursing care protocols and booklets for management of patient with severe nonvariceal upper GIT bleeding.For generalization, conduct this study again with larger sample size and a different government hospital.

Table ( 1
): Distribution of socio-demographic characteristics of study and control groups (total N=80).

Table ( 2
): Frequency of causes of NVUGIB and past medical history among studied subjects (total N=80).