Impact of targeted educational interventions on appropriateness of stress ulcer prophylaxis in critically ill adults
Background: Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB).
Objective: Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST.
Methods: A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests.
Results: Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively).
Conclusion: Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.
2. Zandstra DF, Stoutenbeek CP. The virtual absence of stress ulceration related bleeding in ICU patients receiving prolonged mechanical ventilation without any prophylaxis. Intensive Care Med. 1994;20(5):335-340.
3. Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, Peters S, Rutledge F, Griffith L, McLellan A, Wood G, Kirby A. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med. 1998;338(12):791-797. doi: 10.1056/NEJM199803193381203
4. Levy MJ, Seelig CB, Robinson NJ, Ranney JE. Comparison of omeprazole and ranitidine for stress ulcer prophylaxis. Dig Dis Sci. 1997;42(6):1255-1259.
5. Kantorova I, Svoboda P, Scheer P, Doubek J, Rehorkova D, Bosakova H, Ochmann J. Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial. Hepatogastroenterology. 2004;51(57):757-761.
6. Marik PE, Vasu T, Hirani A, Pachinburavan M. Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis. Crit Care Med. 2010;38(11):2222-2228. doi: 10.1097/CCM.0b013e3181f17adf
7. MacLaren R, Reynolds PM, Allen RR. Histamine-2 receptor antagonists vs proton pump inhibitors on gastrointestinal tract hemorrhage and infectious complications in the intensive care unit. JAMA Intern Med. 2014;174(4):564-574. doi: 10.1001/jamainternmed.2013.14673
8. Alhazzani W, Alenezi F, Jaeschke RZ, Moayyedi P, Cook DJ. Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2013;41(3):693-705. doi: 10.1097/CCM.0b013e3182758734
9. Eom CS, Jeon CY, Lim JW, Cho EG, Park SM, Lee KS. Use of acid suppressive drugs and risk of pneumonia: a systematic review and meta-analysis. CMAJ. 2011;183(3):310-319. doi: 10.1503/cmaj.092129
10. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301(20):2120-2128. doi: 10.1001/jama.2009.722
11. Howell MD, Novack V, Grgurich P, Soulliard D, Novack L, Pencina M, Talmor D. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med. 2010;170(9):784-790. doi: 10.1001/archinternmed.2010.89
12. Kwok CS, Arthur AK, Anibueze CI, Singh S, Cavallazzi R, Loke YK. Risk of Clostridium difficile infection with acid suppressing drugs and antibiotics: meta-analysis. Am J Gastroenterol. 2012;107(7):1011-1019. doi: 10.1038/ajg.2012.108
13. American Society of Health-System Pharmacists. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health Syst Pharm. 1999;56(4):347-379.
14. Barletta JF, Kanji S, MacLaren R, Lat I, Erstad BL; American-Canadian consortium for Intensive care Drug utilization (ACID) Investigators. Pharmacoepidemiology of stress ulcer prophylaxis in the United States and Canada. J Crit Care. 2014;29(6):955-960. doi: 10.1016/j.jcrc.2014.06.025
15. Wohlt PD, Hansen LA, Fish JT. Inappropriate continuation of stress ulcer prophylactic therapy after discharge. Ann Pharmacother. 2007;41(10):1611-1616. doi: 10.1345/aph.1K227
16. Scagliarini R, Magnani E, Pratico A, Bocchini R, Sambo P, Pazzi P. Inadequate use of acid-suppressive therapy in hospitalized patients and its implications for general practice. Dig Dis Sci. 2005;50(12): 2307-2311. doi: 10.1007/s10620-005-3052-4
17. Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol. 2006;101(10):2200-2205. doi: 10.1111/j.1572-0241.2006.00839.x
18. Grube RR, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health Syst Pharm. 2007;64(13):1396-1400. doi: 10.2146/ajhp060393
19. Bulger J, Nickel W, Messler J, Goldstein J, O'Callaghan J, Auron M, Gulati M. Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8(9):486-492. doi: 10.1002/jhm.2063
20. De Rijdt T, Spriet I, Willems L, Blanckaert M, Hiele M, Wilmer A, Simoens S. Appropriateness of acid suppression therapy. Ann Pharmacother. 2017;51(2):125-134. doi: 10.1177/1060028016670414
21. MacLaren R, Campbell J. Cost-effectiveness of histamine receptor-2 antagonist versus proton pump inhibitor for stress ulcer prophylaxis in critically ill patients. Crit Care Med. 2014;42(4):809-815. doi: 10.1097/CCM.0000000000000032
22. Hammond DA, Kathe N, Shah A, Martin BC. Cost-effectiveness of histamine(2) receptor antagonists versus proton pump inhibitors for stress ulcer prophylaxis in critically ill patients. Pharmacotherapy. 2017;37(1):43-53. doi: 10.1002/phar.1859
23. Barkun AN, Adam V, Martel M, Bardou M. Cost-effectiveness analysis: stress ulcer bleeding prophylaxis with proton pump inhibitors, H2 receptor antagonists. Value Health. 2013;16(1):14-22. doi: 10.1016/j.jval.2012.08.2213
24. Tasaka CL, Burg C, VanOsdol SJ, Bekeart L, Anglemyer A, Tsourounis C, Rennke S. An interprofessional approach to reducing the overutilization of stress ulcer prophylaxis in adult medical and surgical intensive care units. Ann Pharmacother. 2014;48(4):462-469. doi: 10.1177/1060028013517088
25. Herzig SJ, Guess JR, Feinbloom DB, Adra M, Afonso KA, Howell MD, Marcantonio ER. Improving appropriateness of acid-suppressive medication use via computerized clinical decision support. J Hosp Med. 2015;10(1):41-45. doi: 10.1002/jhm.2260
26. Meena N, Costner M, Joshi M. Stress ulcer prophylaxis use in the intensive care unit before and after house staff education. J Ark Med Soc. 2015;112(3):38-40.
27. Agee C, Coulter L, Hudson J. Effects of pharmacy resident led education on resident physician prescribing habits associated with stress ulcer prophylaxis in non-intensive care unit patients. Am J Health Syst Pharm. 2015;72(11 Suppl 1):S48-S52. doi: 10.2146/sp150013
28. Buckley MS, Park AS, Anderson CS, Barletta JF, Bikin DS, Gerkin RD, O'Malley CW, Wicks LM, Garcia-Orr R, Kane-Gill SL. Impact of a clinical pharmacist stress ulcer prophylaxis management program on inappropriate use in hospitalized patients. Am J Med. 2015;128(8):905-913. doi: 10.1016/j.amjmed.2015.02.014
29. Hatch JB, Schulz L, Fish JT. Stress ulcer prophylaxis: reducing non-indicated prescribing after hospital discharge. Ann Pharmacother. 2010;44(10):1565-1571. doi: 10.1345/aph.1P167
30. Liberman JD, Whelan CT. Brief report: reducing inappropriate usage of stress ulcer prophylaxis among internal medicine residents. A practice-based educational intervention. J Gen Intern Med. 2006;21(5):498-500. doi: 10.1111/j.1525-1497.2006.00435.x
31. Mousavi M1, Dashti-Khavidaki S, Khalili H, Farshchi A, Gatmiri M. Impact of clinical pharmacy services on stress ulcer prophylaxis prescribing and related cost in patients with renal insufficiency. Int J Pharm Pract. 2013;21(4):263-269. doi: 10.1111/ijpp.12005
32. Anthes AM, Harinstein LM, Smithburger PL, Seybert AL, Kane-Gill SL. Improving adverse drug event detection in critically ill patients through screening intensive care unit transfer summaries. Pharmacoepidemiol Drug Saf. 2013;22(5):510-516. doi: 10.1002/pds.3422
33. Tully MP, Ashcroft DM, Dornan T, Lewis PJ, Taylor D, Wass V. The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32(10):819-836. doi: 10.2165/11316560-000000000-00000
34. Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med. 2005;12(7):629-634. doi: 10.1197/j.aem.2005.02.009
35. Hammond DA, Hughes CA, Painter JT, Pennick RE, Chatterjee K, Boye B, Meena N. Impact of targeted educational interventions on clostridium difficile infection treatment in critically ill adults. Hosp Pharm. 2016;51(11):901-906. doi: 10.1310/hpj5111-901
36. Hope NH, Ray SM, Franks AS, Heidel E. Impact of an educational intervention on steroid prescribing and dosing effect on patient outcomes in COPD exacerbations. Pharm Pract (Granada). 2010;8(3):162-166. doi: 10.4321/s1886-36552010000300002
The authors hereby transfer, assign, or otherwise convey to Pharmacy Practice: (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print pr epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to Pharmacy Practice with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.