What is the Oakland Score?
The Oakland score is a validated risk assessment tool that stratifies patients with acute lower gastrointestinal bleeding (LGIB) to identify those safe for discharge versus those requiring hospital admission, using a threshold of ≤8 points to indicate low-risk patients who can be safely managed as outpatients. 1, 2, 3
Score Components and Calculation
The Oakland score incorporates seven clinical and laboratory variables, with total scores ranging from 0 to 35 points 4, 5:
- Age 3, 5
- Gender 3, 5
- Previous LGIB admission 2, 3, 5
- Digital rectal examination findings 2, 3, 5
- Heart rate 2, 3, 5
- Systolic blood pressure 2, 3, 5
- Hemoglobin level 2, 3, 5
The two main contributors to the score are hemoglobin and systolic blood pressure, where lower values correspond to higher Oakland scores and greater risk 5.
Risk Stratification Thresholds
Patients with Oakland scores ≤8 points have minor, self-terminating bleeds and are safe for discharge with outpatient investigation 1, 2, 3. These patients are characterized by absence of rebleeding, need for transfusion, therapeutic intervention, in-hospital death, and readmission within 28 days 3.
Patients with Oakland scores >8 points have major bleeds requiring hospital admission and inpatient colonoscopy 1, 2, 3.
Predictive Performance
The Oakland score demonstrates excellent discriminatory capacity with area under the receiver operating characteristic curve (AUROC) values consistently between 0.83-0.87 across multiple validation studies 3, 6, 4, 7:
- At ≤8 point threshold: Sensitivity 97-98.4% and specificity 16-98.5% for safe discharge 6, 4, 7
- At ≤9 point threshold: Sensitivity 36.5% and specificity 95% 6
- At ≤10 point threshold: Sensitivity 96% and specificity 31.9% 7
The American Gastroenterological Association recommends using the Oakland score to guide management decisions in hemodynamically stable patients with LGIB 2.
Clinical Application Algorithm
For patients presenting with LGIB 1, 2:
First assess hemodynamic stability using shock index (heart rate/systolic BP) 2
- If shock index >1: Patient is unstable, requires immediate resuscitation and investigation 2
For hemodynamically stable patients: Calculate Oakland score 2
Predicted Outcomes
The Oakland score predicts 30-day adverse events including 1, 4:
- Red blood cell transfusion 1, 4
- Therapeutic intervention to control bleeding (surgery, mesenteric embolization, endoscopic hemostasis) 1, 4
- In-hospital death 1, 4
- Rebleeding (defined as additional transfusion requirements and/or further hematocrit decrease ≥20% after 24 hours) 4
- Readmission with further LGIB within 28 days 4
Important Caveats
The Oakland score may perform differently in populations outside the UK where it was originally developed 3. One US validation study found that extending the threshold to ≤10 points identified a greater proportion of low-risk patients (17.8% vs 8.7%) while maintaining 96% sensitivity 7.
The score may underestimate patients who can be safely discharged due to liberal use of blood transfusions in the derivation population 3.
One study found the Oakland score did not account for baseline anemia, which was present in 59.2% of their patient population and may have artificially elevated scores 5. In this predominantly African American cohort, 96.2% of patients had scores >10 at discharge, yet only 8.33% required readmission within one year 5.
Initial assessment should always include digital rectal examination to exclude anorectal pathology, which accounts for approximately 16.7% of LGIB diagnoses 3.
Cost-Effectiveness Benefits
Early risk stratification using the Oakland score reduces unnecessary hospital admissions, decreases length of stay for low-risk patients, avoids unnecessary transfusions, and focuses resources on high-risk patients 1.