Optimizing stress ulcer prophylaxis in critical care patients


Department of Pharmacy

Presentation Notes

Presented at 2013 Aurora Scientific Day, Milwaukee, WI


Background/significance: Critical care patients are often inappropriately started on proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) for stress ulcer prophylaxis (SUP), or are not re-evaluated when they are no longer indicated. This leads to overutilization in non-ICU patients and failure to discontinue prior to hospital discharge. Both agents have been associated with increased risk of nosocomial pneumonia and an association has been shown between PPIs and Clostridium difficile infection.

Purpose: Improve the appropriateness of stress ulcer prophylaxis agent use in the intensive care units.

Methods: A literature evaluation was conducted to assess qualifications for appropriate SUP. Criteria was made for appropriate SUP and approved by the hospital’s Critical Care physician group. Independent indications included ventilation >48 hours, coagulopathy, traumatic brain or spinal cord injury, burn injury over 35% BSA, major surgery over 4 hours, and GI bleed within the last year. Two or more of the following also indicated patients for SUP: sepsis, ICU stay >1 week, occult GI bleed lasting ≥6 days, hepatic failure, acute kidney injury, hypotension, and steroids over hydrocortisone 250 mg/day or equivalent. Pre-intervention data of the current pharmacological SUP use was collected in the five intensive care units (ICU) at Aurora St. Luke’s Medical Center. The physician group approved a pilot where clinical pharmacists assess each patient for appropriateness of SUP and contact providers to discontinue when necessary. Pharmacists documented their interventions in a month long pilot in one of the ICU units. Following the pilot, approval was granted for pharmacists to automatically discontinue inappropriate SUP. The intervention was expanded to all of the ICU’s at Aurora St. Luke’s Medical Center and ultimately is to be expanded system-wide. Post-intervention was collected in April after implementation in all five hospital ICU’s.

Results: Prior to intervention, 100 ICU patients were followed and SUP use was assessed through their hospital course. Sixty three patients were on SUP, 25 (40%) of which were not indicated. Twenty-six (41.3%) of the 63 patients were continued on SUP at transfer out of the ICU and 10 (15.9%) were prescribed a SUP agent at discharge. In the pilot intervention, pharmacists made eleven recommendations to providers to discontinue inappropriate SUP. Ten (90.9%) recommendations were accepted and resulted in successful discontinuation of unnecessary SUP. Post-intervention, 91 ICU patients were followed and assessed in a similar fashion. Thirty of the 91 patients (32.9%) were on SUP. Thirteen of these 30 patients were not indicated for the agent (43.3%), 20 (66.6%) continued SUP at transfer and three (10%) were prescribed a new SUP agent at discharge. Of the patients not indicated for SUP, pharmacists automatically discontinued agents in three of the patients (23.1%).

Conclusion: Physicians support and agree with the assessments that pharmacists make regarding the need for SUP and pharmacists are in a suitable position to assess the appropriateness of SUP and automatically discontinue the agents when they are no longer indicated. After project implementation, less SUP agents were initially prescribed by physicians in the ICUs; however, further interventions are needed to ensure that pharmacists are making proper assessments and discontinuations.

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